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f/ SAN JOAQUIN LOCAL HLALIH U1SIRILI <br /> F��OFFICE USE: 1601 E. Hazelton Ave-,.-. Stockton, CA 95205 Permit No.--Zf-A. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -L <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 /> loaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS Well #55 pPershin iAve4.& .Woodland Ave CITY/TOWN Stockton <br /> Owner' s Name California Water gervice Company Phone 464-83 <br /> Address 347 N. Sutter St. City Stockton <br /> Contractor's Name Hennings Bros. Drilling Co. Incl icense# 290813Phone 54�-i 185 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURA"ICE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL G DEEPEN 0 RECONDITION ❑ DESTRUCTION M 11+', well <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ll <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ll� <br /> PROPERTY LINE PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 471 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 3,00!t <br /> De tribe Mate—rial and Proced re <br /> r * <br /> I hereby certify that I have prepared this application and that the work will be done in accardan <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 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. " $t <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED Hennings Bros, b @ TITLE: Secretary DATE: 11 -30-28 <br /> (DRAW PLOT L N ON REVERSE= <br /> PRASE I FOR DEPARTMENT VSE ONLY <br /> APPLICATION ACCEPTED BY Ak DATE 7,2 > 8 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSP CTION BY DATE INSPECTION BY DATE//Z <br /> H 4 IRS v. - ° 417 �' `� / ��'`�� /79 2M <br />