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r� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> t Telephone: (209) 466-6781 s.. ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S 11 <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 Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4! <br /> JOB ADDRESS/LOCATION 3521 CHERRYLAND CENSUS TRACT T <br /> Owner's Name ITALIAN ATHLETIC CLUB Phone (931-9933) <br /> Address 3521 CHERRYLAND City STOCKTON ' <br /> Contractor's Name CLARK WELL & EQUIPMENT CO. License # 76602 Phone 462-5597 <br /> TYPE OF WORK (Check) NEW WELL /g/ DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / !/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2jo_-,�-SEWER LINES - PIT PRIVY ' <br /> SEWAGE DISPOSAL_,.FIELII Aagz-# CESSPOOL/SEEPAGE PIT OTHER <br /> I. PROPERTi LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> mastic/private DA1Zed ` Dia. of Well Casin <br /> Domestic/public Driv Gauge of�Gasing <br /> Irrigation � �' avel Pack ' Depth of Group'"Seal � <br /> 4 Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informationt <br /> Geophysi&a1 } f Surface Seal Insta'11ed BY: r <br /> } <br /> PUMP INSTALLATION: Contractor 1 <br /> t�- Type of Pump >- :.. " H.-P. r T <br /> , PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:. / / State Work Done ` 1s <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material and Procedure," i <br /> f <br /> I hereby agree to comply with all laws d,,regulations of the San Joaquin Local Health District <br /> and the State of Califor.iiia= pertaini.ng-to -or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my/work onia-tiew well,"I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of rtiie well and notify them before putting the .well in use. The above. <br /> information is—true "to=°Che best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUT G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT,PLAN ON-REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I .�T - <br /> APPLICATION ACCEPTED BY _ DATE S 8 <br /> ADDITIONAL COMMENTS: <br /> P E GROUT INSPECTIO PHA E III FINAL INSPECTZO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 IV _ 2Ni <br />