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SAN JOAQUIN LOCAL. HEALTH DISTRICT � <br /> 1601 E. Hazelton Ave. , ,Stockton,,Stockton, Calif. # <br /> -70-9-"OFFICE USE.: � <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 /> Applicattion is �iereby made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San i6aqutn'. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. + <br /> JOB ADDRESS/LOCATION 13294 E. Harney Ln. ; in yard, 20' from. CENSUS TRACT <br /> South side of house <br /> Owner's Name PAT GALLAGHER Phone <br /> - 13294 B.. Harneyz Lane City Lodi <br /> Address . <br /> Contractor's Name GOEHRTNG PUMP & IRRIGATION, INC. License # 309031 Phpne '727-5548 <br /> ,.•� �� <br /> TYPE OF WORK (Check) : NEW WELL f_1 DEEPEN RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALMP LATION PUREPAIR �/ PUMP REPLACEMENT /� <br /> Other / / . a <br /> .0 <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY . <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 v t 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 /> �� Other �_ Other Information <br /> Disposal ,N <br /> -`S_urface S"eat Installe �By="'�'-` T <br /> T 77 <br /> PUMP INSTALLATION: Contr.actor� '; . �__ H . 20 <br /> Type of Pump turZj'_ne H.P. <br /> PUMP REPLACEMENT: ,/=/; State Work Done4., § _ <br /> PUMP .REPAIR• / '} State Work Done 30' extension and new bowls <br /> DES•TRUCTION -OF WELL: W611 ,Diameter: Approximate Depth <br /> Describe Material and Procedure <br /> r I ;hereby agree to comply with all lawns and regulations of the San Joaquin Local Health istrict <br /> and the State. of California pertaining to or regulating we11 ''construction. Within FIFTEEN DAYS <br /> C 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 /> k information rue to 'the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AD A_ FINAL INSPECTION. <br /> SIGNED TITLE_ <br /> (DRAW PLOT PLAN ON REVER§E SIDE <br /> j ;f FOR DEPARTMENT USE ONLY Ew <br /> PHASE It '{DALE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL�r+COMMENTS:� .: r'.;vi PHASE III/•FINAL.INSPECTION <br /> P S II.,GROLTT`INSPECTION INSPECTION BY{ " ' ' # .1 'DATE - .3 1 <br /> INSPECTION BY ..� ``"DATE <br /> �+ 1777 2H <br /> i�. u `7 AI)r w uo,r_ 1-74 <br />