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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif.- <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1,12*17e <br /> THIS PERMIT EXPIRES l YEAR FROM DATE��ISSUEDfv. Date Issued <br /> t (Complete In Triplicate) <br /> Application is hereby made to `the San Joaquin Local Health District fora 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 /> JOB ADDRESS/LOCATION I M11a narth maripoza d #79 S.f..rajjr0adCENSUS TRACTln-IS_-VE <br /> Owner's Name MU3Whj 13 <br /> r-Os. Phone <br /> Address 3743 East .Poothill Blvd. City <br /> Pasadena- <br /> Contractor's Name Clark Well & Equipment Co ; License #76602 Phone 462--5597 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 v <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Vj <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation 4" <br /> Domestic/private Drilled Dia. of Well Casing <br /> - 3 <br /> . Domestic/public Driven Gauge of Casing <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 /> , <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material: and Procedure <br /> I'hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN.DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districi.t a <br /> kl;L <br /> WDRILLERS REPORT of the well and notify them before putting the well in use. The 'above <br /> information: is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A FINAL INSPECTION. <br /> SIGNED TITLE G . <br /> t ✓ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> „; FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �"1� a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1/77 _ : 2M <br /> V 'u`iA0ti n ,, 1_7A <br />