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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br />_EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 <br /> Telephone: (209) 466-6781 <br /> Date Issued74 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT V } <br /> This Permit Expires 1 Year From nate Issued <br /> Complete In Triplicatel a <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 /> Joaquin County Ordinance- No. 1862 and the Rules and Regulations of .the San Joaquin Local Health <br /> District. ` <br /> EXACT STREET ADDRESS Rt 1 ,Box 48Nhir - 14 '2 5 CITY/TOWN Iselton <br /> Owner' s Name Bouldin Farming Co. ,Inc. Phone 916- -6091 <br /> Address- Rt .-1 ,Box 48N. Highway 12 City Iselton <br /> Contractor's Name Clark Well & Equip.Co. ,Inc- Li cense# 76.602 Phone 462-5597 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURANCE V1 FILE WiTH'SJLHD?' ` YES NO � <br /> TYPE OF WORK (Check) : NEW WELL ID DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ . <br /> -WELL-CHLORTNATI-ON-❑ —WELL ABANDONMENT-ED—OTHER-0— <br /> PUMP <br /> BANDONMENT❑ OTHER"❑PUMP INSTALLATION ❑ _PUMP REPAIR❑- PUMP REPLACEMENT {� _ <br /> DISTANCE TO NEAREST:----S-EPTIC TANK/pp ---SEWE-R—LI�ES/W PIT PRIVY <br /> SEWAGE DISP SAL FIELD ,/66CESSPOOL/SEEPAGE IT�z,&THER ;. ___ <br /> PROPERTY LINYAWIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> - INTENDED USE USE TYPE OF­WELC a. CONSTRUCTION SPECIFICATIONS <br /> / Industrial Cable Tool Dia:, of Well Excavation 101,548,1 <br /> x Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing____ <br /> ass 6 <br /> .Irrigation Gravel Pack Depth of Grout Seal o Impervious c ay <br /> Cathodic Protection x Rotary Type of Grout Bentonite Quik-Gel <br /> Disposals-1. 'f Other Other Information <br /> Geophysical �, Surface Seal Installed by: <br /> PUMP INSTALL-ATI.ON: Contract or <br /> Type of Pump �. �- H.P. <br /> PUMP REPLACEMENT: [].State Work Done *� <br /> PUMP REPAIR: /E3 State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter # Approximate Depth <br /> Describe Materia and Proce ure <br /> F .. <br /> I hereby certifyrthat I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , 'and Rules and Regulations of the San-Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I' certi'fy that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CAL F R ECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE. ie <br /> m- , <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR D RTM£NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />,INSPECTION BY DATE INSPECTION BY C. 13- DATE -3 4a <br /> ru 1 n119: D. 1� 77 1 178 2M <br />