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SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 31:"5 <br /> f <br /> II THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (0 4 <br /> (Complete In Triplicate) <br /> { Application islIereby 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. 18, and the Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION 1100 E Harney Lane CENSUS TRACT <br /> ..q, 7 Phone <br /> Owner's Name ED SCROLL <br /> II R <br /> Address 1100 -E Har'hey Lane City Lodi <br /> �I <br /> Contractor's Name Goohring Pump & Irriaation,Inc. License # 309031Phone 727-5T 548 <br /> � Q44 4 <br /> (TYPE OF WORK (Check)+: NEW WELL L-7 DEEPEN /� RECONDITION [T DESTRUCTION /-] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD--n DESSPOOL/SEEPAGE PIT OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLICDOMESTIC WELL <br /> INTENDED USE I� TYPE OF WELL l-• CONSTRUCTION SPECIPICATIONS <br /> Industrial Nq Cableoo1 I.., Dia ';of We <br /> 'Tll` Excavation �_ F <br /> SII Domestic/private Drill4d� Dia of Well Casing <br /> ,I Domestic/public ' Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Dept11 <br /> h'of Grout Seal <br /> �I Cathodic Protection ! Rotary Type of;Groyt <br /> Other Other Information <br /> Disposal ,Ij ° 1?57 jib. ,! Surface Seal! Installed Bv: <br /> Geophysical'"- ! .- <br /> PUMP INSTALLATION: Contractor - Z•. r•:'• <br /> PUMP REPLACEMENT: / State Work Done replaced 3HP ret butdA w! 2HP MS�rG ai hmarci <br /> pti 1 <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 bistrict , <br /> and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> I after completion of m; 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-TO-- <br /> SIGNED <br /> A±'FINAL`INSPSCLION. <br /> SIGNED - TITLE •�.;,-. <br /> P1 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ` FOR DEPART T USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE G; <br /> ADDITIONAL COMMENTS:- pHASE III/FINAL INSPECTION <br /> PHASE I1• GROUT INSPECTION DATE7--S4- <br /> INSPECTION BY $ DATE INSPECTION BY lJ• i ` <br /> .x/77 _ 2H <br /> E H 1426 Rev. 1174 <br />