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1 <br /> SAN JOAQUIN .LOCAL 'HEAL-IH DISTRICT <br /> AOR ,QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._2f-,'/ <br /> Telephone: (209) 466-6781 <br /> APPLICATIQN- FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S-/y- 7 y- <br /> This Permit Ev ires 1 Year: From Date Issued <br /> Complete In Trip icate nb 037) 4 <br /> Application is hereby made to- the San Joaquin. Local Health District -for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,.'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 'Health , <br /> JiStriCt. � 1yfV,.,, ,. :r� = s <br /> EXACT STREET ADDRESS <br /> RT 1 BoIselton CA CITY/TOWN Ixselton <br /> Owner' s Name Bouldin _Farming Co, Inc. Phone 916-777-6091 a <br /> Address RT 1'--,Box 4$N City Iselton <br /> Contractor's Name Cla Well & E uip.Co. ,Inc License# 76602,,_ ..PPhon x.,462-097 <br /> IS CERTIFICATE OF WQRKtIAP�' COMPENSATION INSURANCE ON FILE WITH SJLHD? Y S NO <br /> TYPE OF WORK (Check) : NEW WE L DEEPEN ❑ RECONDITION ❑ D/EST ❑ <br /> a <br /> WELL CHL .INATION ❑ WELL ABANDONMENT ❑ 0 ER❑ _ o <br /> PUMP INSTAL ATION ❑ PUMP REPAIR❑ PUMP EPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK #1 0 SEWER LINES *1 0 PITZE <br /> Y <br /> SEWAGE DISPOSAL ELD +150 CESSPOOL/SEPIT OTHER <br /> PROPERTY LINE -. P VATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WEXkh CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable TWell Excavation 10 <br /> Domestic/private Drilled Well Casing " <br /> -�-r Domesti c/pub.l i c Drivenf Casing Glass 1 4iNIrrigation Gravel f Grout Seal to mperVious cly <br /> Cathodic Protection x RotaryGrout Benonite Quik-Gel <br /> Dts.po-sal Othernformation <br /> Geophysical Sea Installed bPUMP INSTALLATION: Contractor <br /> Type of Pump A , H.P. <br /> PUMP REPLACEMENT: ❑State Work Doe � : � � <br /> ON 4F <br /> PUMP REPAIR: ❑State Work one f <br /> DESTRUCTION OF WELL: Well Diame r 1 , roximate Depth r ' ' <br /> -- # ,Describe ateri a , an Procedure <br /> I hereby .certify that'I' hav prepared this application and that the work 11 be.done -jri" accordance <br /> with San Joaquin County dinances , Statev .Laws , and Rules and Regulations-..o the San Joaquin Local <br /> Health District-,,,Home wner or licensed agent' s signature certifies the, fol. wing: + <br /> "I certify- thaf-si.ni' the-performance of the work for which this permit is iss d, I shall <br /> not employany-p6rson in such-manner. .asr_to become subject- to Workman's-Compe sation <br /> laws =of Cal ifor6ia. ' . ._. <br /> I WILL CALL _GROUT= NSPECTION�PRIOR-TO­GROUTINGv`AND A FINAL`INSPECTION. <br /> SIGNED t ' _ - '� TITLE :-, DATE: <br /> AW PLOT .PLN ON--REVERSE SIDE) <br /> , <br /> *; FOR .DEP TMENT USE ONLY <br /> PHASE I ,�..0 <br /> APPLICATION ACCEPTED._ B r , ,I. DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION. BY DATE INSPECTION BY DATE <br /> Cu 7AOC n,... in '77 1752��`lM , <br />