Laserfiche WebLink
41 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 F 0)?FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7_ M10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7=/-1` 77 <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 236 1/2 Cherry St. - Well 6 _ CENSUS TRACT 32250 <br /> Owner's Name C i ty of Lodi Phone 368-0641 <br /> Address 221 W. Pine Street City Lodi <br /> Contractor's Name --- License # Phone <br /> L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 127 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINES 20' PIT PRIVY --w <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT --- OTHER to rain-5' <br /> PROPERTY LINE 7 PRIVATE DOMESTIC WELL..' --- PUBLIC, DOMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 ' I k:4 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. y" <br /> PUMP REPLACEMENT: / / State Work DoneVN <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 ofmy w rk on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o he well and notify them before putting the well in use. The above <br /> informat n is ue to e b t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTt FTN INSFECTION. <br /> SIGNED TITLE Publico <br /> Ja k L. Ronsko DRAW PD T PLAN ON REVERSE SIDE See attbched dKeat <br /> \",J FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ✓ l DATE <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE IIIjFINAA1 INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />