Laserfiche WebLink
- r , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> FOR OFFICE E: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone : (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - Iµ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 23 <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 /> JOB ADDRESS/LOCATION Well #6 - 2362 Cherry Street '� `r <br /> CENSUS TRACT <br /> Owner's Name City of Lodi Phone 368-0641 ex. 204 <br /> Address 221 West Pine Street City Lodi <br /> Contractor's Name _ City of Lodi License # N/A Phone368-0641 <br /> ex. 204 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION /X/ 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 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private X Drilled Dia. of Well Casing 13\ <br /> X 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 /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /X/ State Work Done 1m ellar shaved <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 District a <br /> WELL DRILLERS 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 GROUTING AND A FINAL INSP CTION. <br /> SIGNED TITLE Water/Sewer Supervisor <br /> DRAW PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEg 2 - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I ,I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY rn DACE <br /> E H 1426 Rev. 1-74 rel 3/76 2 <br />