Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> t Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j,t�;0 <br /> t THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> l <br /> crr`( 7 .4-­�ur--,-v^/e .GD , (Complete In Triplicate) <br /> App cation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> kand/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.': <br /> JOB ADDRESS/LOCATION <br /> ari osa rd #79 & s .f.railroacUENSUS TRACT tri-1S-R7E <br /> fOwner's Name - 11• <br /> ro, Phone <br /> Address 4East Foothill Blvd. Cit Pasadena <br /> City _ <br /> Contractor's Name Clark Well &� E` ,flIbment C-0 _ �i7�tI License- A76602`-5';Phone 462-5597 <br /> t t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /�� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <br /> ; DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'F <br /> PROPERTY LINE -- PRIVATE DOMESTIG WELL PUBLIC DOMESTIC .WELL <br /> INTENDED USE 3 .TYPE+ OF WELL` CONSTRUCTION SPECIFICATIONS <br /> Industrial' };' Cable Tool Dia. of Well Excavation 1411 I <br /> Domestic/private 0—.4r.. Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ` <br /> x< � rig�Irigationr_ . GravePack Depth of Grout Seal <br /> 1 . r3 : <br /> a�Ca'tl ooIc7'4_ote•ction Rotary Type of Grout <br /> Disposals Other Other Information <br /> Geophysicalr Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump <br /> I <br /> PUMPREPLACEMENT: <br />� / % `,S-tate Work Done <br /> y � t 6 � <br /> f PUMP .REPAIR: / / tateWork Done <br /> 112ESTRUCTION OF WELL: Well Diameter r -`, "Approximate De th A � <br /> Describe MaterialFand Procedure <br /> CI hereby agree to comply with all laws and regulations of '.,tties.5an Joaquin• Local Health District <br /> Eand the State of California pertaining to or regulating':,we`l1'"-constru-tion. Within FIFTEEN DAYS <br />,after comp le tion' of,myjwork on a new well, I will furnish San Joaquin Local Health District a <br /> WE1l�'r:DRTLLERS REPORT of the well and notify them before put.t3ng the .well in use.. The above <br /> L infbrmati6n .is .true to. the �'t�of y knowledge and�be ief I WILL CALL FOR A GROUT INSPECTION <br /> _,_ �.,* . <br /> PRIOR"TO TI `G' kA�FrNAL INS1'' CTION � <br />( SIGNED TITLE <br /> (DRAW-PLOT-'p AN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY A/ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ,f <br /> PHASE II GROUT .INSPECTION P INSPECTIO <br /> INSPECTION BY /DATE INSPECTION B �.DATE r Z <br /> E_H_ 1426 Rev. 1-74 - : 1177 _ 2M <br />