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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> jFOT-,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 v <br /> .� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br />. i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued h_4 <br /> (Complete In Triplicate) <br /> Application is-tereby niade toy"the San Joaquin Local Health District for a permit to construct <br /> k <br /> "4n d/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 /> lJOB ADDRESS/LOCATION 11100 E. Harney Lane CENSUS TRACT <br /> Phone <br /> Owner's Name ED SCHOLL <br /> �j <br /> (Address 1100•~E. Harney- Lane City Lodi <br /> ► �1 �! License # 30903lPhone '727-5544 <br /> t Contractors Name Goehrin Pum & Irri a-Lion Lnc. <br /> � ITYPE OF WORK (Check): NEW WELL / I DEEPEN 17 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION J I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other . / J ,., <br /> %:DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY0. <br /> C <br /> i � SEWAGE DISPOSAL FIELD QESSPOOL/SEEPAGE PIT OTHER C <br /> I�. s PROPERTY LINE -- PRIVATE DOMESTTC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `�7, t CONSTRUCTION SPECIFICATIONS <br /> ' 1 I f <br /> Industrial t Cab <br /> Dia Well'' Excavation ` <br /> II Domestic/private D.rill�d` Dia..-of„Well Casing <br /> I Domestic/public Driven Gauge of Casing <br /> Irrigation ? Gravel Pack Depth;�•of Grout Seal 5 <br /> G.I Cathodic Protection Rotary Typeof�;Grout - <br /> ➢is osal Other . Other Information <br /> Geophysical Y''' r ty�' ` `J Surface Seal3 Installed BY: 1 <br /> PUMP INSTALLATION: I Contractor <br /> ,­Typ.e_...o.f <br /> `PUMP REPLACEMENT: , State Work Done re laced 3HP jet punilp ZHP 1 <br /> PUMP REPAIR: / / State Work Done <br /> �.. Approximate Depth <br /> !DES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> � I hereby agree. -to comply with all laws and regulations of the San Joaquin Local Health bisirict . <br /> and the State of California pertaining to or regulating well 'constructian. Within FIFTEEN DAYS <br /> I after completion ofmy work on a new well, I will furnish the San Joaquin Local Health District i <br /> WELL DRILLERS ORT of the well and notify them before putting the- well in use. The above <br /> information e o the best of my knowledge and belief. TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR°TO-G �A`FTNAL�INSPE.CT.ION. <br /> SIGNED TITLE <br /> (DRAW PZOT PLAN ON REVERSE SIDE <br /> FOR DEPARTME T USE ONLY <br /> ZI <br /> PHASE I s <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS:. <br /> PHASE II'� GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY 1k DATE INSPECTION BY DATE <br /> 1 <br /> 117.7. _ 2M <br /> E H 1426 Rev. 1=74 <br />