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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br />_OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9,_4Y <br /> Telephone: ,(.2a . , 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issueds_/5-?Z C <br /> This Permit Expires 1 Year From Date Issued f <br /> Complete_ In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct f <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. �.o_�o.t�v+/ 06.Ct- 030-5 I <br /> EXACT STREET ADDRESSox 48N JH!Zh-wa �12 CTTY/TOWN Iselton <br /> Owner's Name Boul in Farming Co. Inc. Phone-916-7.2-2-6091 <br /> Address Rt 1 Box 48N.-Highway 12 . Ci tY Iselton. p <br /> Contractor's Name Clark Well . & EQuip_. Co. ,Inc. License#?6602 _ Phone 462-5597 <br /> ..._ - �� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I'ISURA^!CE OPf-FILE WITH SJLHD? '` YES NO <br /> TYPE OF WORK (Check) : NEW WELLLN DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ C <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ED OTHER ❑ o l <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK+c < . SEWER LINES+50 PIT PRIVY �(,��t•Pi <br /> SEWAGE DISPOSAL ,FI,ELD ,g-0 r CESSPOOL/SEEPAGE PIT��trUTHER <br /> PROPERTY LIN5&yPRI,VATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELD ``ti CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool �` Dia. of Well Excavation 10 " <br /> T�Domestic/private Drilled Dia. of Well Casing 6 5 " <br /> Domestic/public Driven Gauge of Casing Class 1 6n <br /> Irrigation Gravel Pack Depth of Grout Seal to impervious clay <br /> Cathodic Protection x Rotary Type of_Grout Bentonite Quik-Gel <br /> Disposal ,7 .,Other Other Information <br /> _ Geophys i cal ,... '-_� .` .Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump s -- -s H.P. <br /> PUMP R.tPLACEMENT: State Work Done <br /> PUMP REPAIR: � , ;f. � ❑state Work Done <br /> DESTRUCTION .OF WELL: t Well Diameter AJ*, Approximate Depth <br /> Describe Material and Procedure - - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> 4with San Joaquin County Ordinances., State-Laws , and Rules and Regulations of' the San Joaquin Local <br /> Health District: Home o'wne"r -or licensed agent' s signature, certifkies the following: <br /> "I certify that in the perfoi^i�ance of the work far which ch this permi.t._i s_issued, I shall <br /> not employ any perso'n. in_.'such manner as to become subject to Workman' s Compensation <br /> laws_.of- C -1 i for ' I ' . / <br /> I WILL CA OUT CT ON P IQR ,.O-GROUTINO AND A FINAL INSPECTION. <br /> SIGN } TITLE aJ DATE. <br /> II <br /> --- -,..--(DRAW PLOT .PLN ON REVERSE SIDE <br /> FORD ARTMENT USE ONLY <br /> PHASE `I. -'" e- <br /> APPLICATION ACCEPTED BY DATE <br />;ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> INSPECTION BY r— DATE INSPECTION BY DATE <br />'rn iAne n_.. ,n -7-71 1 /7R 2M <br />