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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit .Ex ices 1 .Year From Date Issued <br /> Complete In Triplicate p 6 X30 <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 a' u a tons he SarLALoaUin Local Health <br /> District. ' u <br /> EXACT STREET ADDRESS Rt f Box 48N I1hwabor Cam CITY/TOWN Iselton <br /> 4 <br /> Owner's Name Bouldin Farming Co. , Inc. Phone 916-777-6021. <br /> Address RT -1 Box 48N Highway 12 City Iselton <br /> Contractor' s Name Clark Well & Equip.Co: ,Inc. . License#76602 Phone 462-5597 <br /> IS CERTIFICATE OF, <br /> WORKflki'S CO�1PEfdSATIO`S INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLED DEEPENED RECONDITION C] DESTRUCTION E) <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ . . <br /> DISTANCE TO NEAREST:, SEPTIC TANK +100 SEWER LINES +100 PIT PRIVY +100 <br /> f SEWAGE DISPOSAL FIELD+100 CESSPOOL/S�EPAGE PIT +100 OTHER _+100 <br /> PROPERTY LIN (,,� IVATE DOMESTIC WELL 1 00BLIC DOMESTIC -WEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I dustrial -ECablenTool Dia. of Well Excavation <br /> domestic/private Drilled' , Dia: of Well Casing 6. <br /> X Domest.i.c/public Driven Gauge of Casing Class 13 - <br /> Irrigation-.ti, Gravel—Pack Depth. of Grout Seal to im envious clay <br /> . Cathodi c Protection,: X Rotary Type of Grout Bentonite Quik'-Gel <br /> Disposal Other ; Other Information <br /> -Geophysical Surface Seal Installed by: i <br /> PUMP'INSTALLATION: Contractor— <br /> _ Type: of -Pump H.P. <br /> PUMP REPLACEMENT: []State WorkRDone r <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF ,WELL: Well Diameter _ Approximate Depth <br /> DescH be' Materia and Proce ure -' - <br /> i hereby certify that 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 certify that. in ,the-per..formance-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 ,tompensation <br /> laws of California." f <br /> I WILL COL/F R NSVECTIOq PRIOR TO GROUTING AND FziVAL INSPECTION. <br /> SIGNED , <br /> r _ TITLE: - _ . .. DATE: <br /> Z-R W PLOT PLN ON REVERSE SIDE <br /> ^� RX PARTMENT USE ONLY <br /> PHASE 2I - r <br /> APPLICATION ACCEPTED BY ry .yf `., - DATE r <br /> ADDITIONAL-COMMENTS : -­ __�. - : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ..� INSPECTION'BY ' k C•, DATES 3 2�j <br />