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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOE OFFICE USE: ! 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-64 p <br /> i� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) a permit <br /> Application is hereby made to the San Joaquin Loapplo construct <br /> �icatia ealthnistmade inrict rcompliancetwi.th San Joaquin <br /> and/or install the work herein described. <br /> County Ordinance Na. 1862 and the Rule and Regulations of the San Joaquin Local Health District. <br /> A&A �� � CENSUS TRACT <br /> JOB ADDRESS/iILOCATION SKS ' <br /> _ r <br /> Phone \� <br /> Owner's Name <br /> City <br />� Address Ski\ r \ A <br /> hone <br /> License ��C, <br /> Contractor's Name `! <br /> _ <br /> TYPE- OF WORK (Check) : NEW WELL /✓! DEEPEN '/ I RECONDITION p pEREPLACEMEN- 1-7 <br /> PUMP INSTALLATION /PUMP REPAIR I;I y <br /> �:- <br /> - other 1 I <br /> DISTANCE TO' NEAREST: SEPTICr TANKQ`ter SEWER LINES ��`-'Y PIT PRIVY <br /> OTHER <br /> SEWAGE DISPOSAL, FIELD _- CESSPOOL/SEEPAGE PIT �� - p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE f; TYPE OF'WELL CONSTRUCTION SPECIFICATIONS <br /> CableTool Dia. of We11 Excavation \� <br /> k Industrial Dia. of Well Casing 51 <br /> Domestic/private Drilled <br /> ! rivate � !Driven r'; Gauge of Casing \2. <br /> Domestic/public <br /> Irrigation ! Gravel Pack, Depth of Grout Seal 2� <br /> �. Rotary Types of Grout <br /> Cathodic Protection t Othe,Information <br /> - Other <br /> Disposal <br /> x <br /> Surface�S,eal Installed B : <br /> Geoplysical <br /> PUMP INSTALLATION: Contractor P. <br /> f ----"-----�-TY-pe_of-P.ump <br /> PUMP REPLACEMENT: I / State ,Work Done4 <br /> PUMP .REPAIR: l Im State Work Done <br /> Approximate Depth <br /> DFS•TRUCTION 'OF WELL: Well Diameter <br /> Describe Material and Procedurestrict <br /> -. <br /> i, <br /> i. _ _ _ <br /> I hereby-a•gree--to-comp1-y"with---allininsbtodoreregulating welle'construction.LoWithinaFIFTEtN,J)AYS <br /> and the State of CaliEornia, perta g <br /> after completion of my work on a new well, I will furnish <br /> rnishthe <br /> uttingatheowelln.nQuse.HeThehabp er ct ` <br /> WEL -DRILLERS--REPORT^of-�thewel and-notify-them be p <br /> infor ion is true to st my knowledge and belief. I WILL CALL FOR A GROUT INSF�CTION <br /> PRIOR OUTING AND' FI E N. TITLE <br /> +� <br /> TITLE <br /> i dle <br /> SIGNED <br /> - in) W PLOT PIAN 'ON RE L'RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHAS ' DATE <br /> APPLICATION ACCEPTED:< <br /> ADDITIONAL COMME PHASE III/FINAZ INSPECTION <br /> p ! OUT INSPECTION DATE j-- I l <br /> INSPECTION BYE° DATE / 7 <br /> INSPECTION BY <br /> 3/76 2M <br /> E H 1 <br /> 426 Rev. 1-74 - <br />