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SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> FOF_-�14FFT-% USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o�-/Y 7 <br /> (Complete In Triplicate) V <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 /> 1 <br /> JOB ADDRESS/LOCATION 12611 E. Peltier CENSUS TRACT <br /> Owner's Name Joe Wesley Phone 931-4201- <br /> Address 12872 E .., Atkinson Road !Lodi <br /> City <br /> Contractor's Name Owner License // Ph'&n' <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-T _ <br /> PUMP INSTALLATION / PUMP REPAIR J / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 128ft SEWER LINES -PIT PRIVY <br /> SEWAGE DISPOSAL ,FIELD 15Oft.CESSPOOL/�SIE-EPAGE P T _� OTHER <br /> PROPERTY LINE/IWPRIVATE DOMESTIC WELL/& PUBLIC DOMESTIC W LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI I NS <br /> Industrial Cable Tool Dia, of Well Excavation r <br /> —�~ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal A0 <br /> Cathodic Protection X Rotary Type of Grout sack I <br /> Disposal Other Other Information - 5Z:- ,6 <br /> e <br /> Geophysical Surface Seal Installed By <br /> _. ._ <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump Sears it.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done �- <br /> DESTRUCTION OF WELL: Well DiameterAl J4. <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sara. 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 well in use.. The above <br /> information is true to the best of my kn wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI D A-FINALA ECT 0 y. <br /> SIGNED _ TITLE Owner <br /> DRAW PLOT AN ON REVERSE SIDE) ^T <br /> F PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE' A` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYr DATE ' <br /> E H 1426 Rev. , 1-74 <br /> _ 2M <br />