Laserfiche WebLink
�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i <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 /> EAST SIDE OF AMPINE RD SOUTH OF REALTY RD <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Rddney SCHATZ Phone ' 369-3321 <br /> Address a KXXT we 16100 N* ALPIR RD City LODI <br /> Contractor's Name SAN JOACJJIN PJNP CO• License # Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION (Z7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1n <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMES IC 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 /> 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 SAN JO IN Ptd CO. <br /> Type of Pump SUB BPZIBLE - STARVE H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L7 State Work Done <br /> nSTRUCTION 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 s . <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 'a AYNSPECTION <br /> PRIOR TO GROUTING AND A FINAL MSPECTION. <br /> SIGNED TITLE (Division of San Joaqule4 hour Co.) <br /> DRAW PLOT PLAN ON REVERSE SIDE 569 { <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,2;0� 7f r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> t E H 1426 Rev. 1-74 1-74 2M <br />