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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. �_g l 74 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /d„f4_$- <br /> (Complete In Triplicate) <br /> Application is Aereby 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 16500 E . Brandt Rd. CENSUS TRACT <br /> Owner's Name Lee Brewer Phone ' <br /> Address 16500 E. Brandt Rd. City ' Lodi <br /> Contractor's Name Goel2rincrPump & Irri ation, Inc. License # 309O3lPhone .727-5548 <br /> TYPE OF WQRK .(Check) :~ NEW WELL /—/ DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 T -V <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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�� Com? <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: )W State Work Done replaced 15HP turbine with 72HP Mye.,s sub. <br /> PUMP ,.REPAIR: / / State Work Done <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 strict <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 a to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FINAL INSPECTION. <br /> SIGNED TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> AOR DEPARTMET USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY :Z-7 DATE ! /4 7i, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -_reDATE <br /> E H 1426 Rev. 1.-74 1177 2M i <br />