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SU0007444 SSCRPT
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SU0007444 SSCRPT
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Last modified
5/7/2020 11:33:04 AM
Creation date
9/8/2019 12:41:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
FileName_PostFix
SSCRPT
RECORD_ID
SU0007444
PE
2622
FACILITY_NAME
PA-0800322
STREET_NUMBER
5601
Direction
W
STREET_NAME
PELTIER
STREET_TYPE
RD
City
LODI
APN
00304012
ENTERED_DATE
10/27/2008 12:00:00 AM
SITE_LOCATION
5601 W PELTIER RD
RECEIVED_DATE
10/27/2008 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\P\PELTIER\5601\PA-0800322\SU0007444\SSC RPT.PDF
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EHD - Public
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SAN JOAQUIN LOCAL HEALTH DISTRIi:'f <br /> � FOR�OFFICE USE: 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 <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/LOCATIONv�y,��Nj,� %? ,,� , r �� (-/ 1,� CENSUS TRACT <br /> Owner's Name Phone <br /> Address lT (= / City <br /> Contractor's Name C/.f�j7j� ,�%�=L� /. C/ i� License ll <br /> Y,�Ga " PhoneS'�,��.�.5 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /% PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other f-1 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY T <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - 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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation a Gravel Pack Depth of Grout Seal R <br /> Cathodic Protection T� Rotary Type of Grout a <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 C\ , <br /> PUMP :REPAIR: /-7 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 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 wdll in use. The above <br /> informatiffn is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTfON <br /> PRIOR TO G'ROUTING D A FINAL INSPECTION. \� <br /> SIGNED TITLE �✓ ti/u <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I jZ�JDAPARTMEN.T USE ONLY <br /> APPLICATION ACCEPT L SLS DATE �Q_ <br /> ADDITIONAL COMMENTS: 7.7 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> JNSPECTION BY DATE INSPECTION BY . DATE .�-iS• <br /> E H 1426 Rev. 1-74 „ �„ <br />
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