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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> J Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��� ✓�d <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 Jopquin. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION 3610 Section Avenue <br /> CENSUS TRACT <br /> Owner's Name Trinidad Garcia Juarez Phone <br /> t <br /> Address 361.0 Section Avenue City Stockton <br />' t <br /> Contractor's Name Clark Well & Equipment Co. License #76602 Phone 462 <br /> f 1 <br /> _ i <br /> TYPE OF WORK (Check) : NEW WELL Al DEEPEN/ / RECONDITION DES_/ /_ E TRUCTION /_ p <br /> PUMP INSTALLATION; ,/, V i PUMP, <br /> ;REPAIR}/ / PUMP REPLACEMENT /? <br /> _0t . <br /> her /: <br /> DISTANCE TO NEAREST: SEPTIC TANK 2,51)/ <br /> SEWER LINES j _. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL./SEEPAGE PIT OTHER Q <br /> PROFERTY.LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toal Well Excavation O <br /> Domestic <br /> /private Drilled Di'a. of Well Casing 1 01" <br /> Domestic/public Driven "'- -�- -,.Gauge of Casing <br /> X Irrigation e :. Gravel Pack ;-Depth of Grout Seal <br /> Cathodic Protection X= Rotary 14,Typetof Grout t: <br /> Disposal a it Other Other' Infdrmation <br /> Geophysical a <br /> + . -Surface Sgal Installed B <br /> }- <br /> PUMP INSTALLATION: Contractor -fa- lrw ` <br /> a --Type of Pump ., H.P. ' <br /> , a <br /> PUMP REPLACEMENT w % / State Work Done <br /> PUMP REPAIR: State Work Done ''- <br />`DES-TRUCTION OF WELL: .2'-Wl ell Diameter � .1, '; / ~` {: ' . Approximate De th <br /> DeDep Materia 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 District a <br /> WELL DRILLERS REPORT ofsthe 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 GROUTINP AND AFI INSPECTION. + x:c , . <br /> SIGNED `TITLE Owner ;I <br /> t (D W PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY a <br /> PHASE I <br /> APPLICATION ACCEPTED $Y' , <br /> ADDITIONAL COMMENTS: DATE — <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION, <br /> INSPECTION BY _ 31 DATE INSPECTION BY- DATE-1,- <br /> �r3 <br /> E H 1426 Rev. 1-74 +` IJ77 <br />