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FOR OFFICE USE Gg SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm <br /> k it No. <br /> k THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUEDb <br /> I Applications hereby (Complete In Triplicate) Date Issued <br /> made to the San Joaquin Local Health District <br /> for apermito- <br /> � and/or install the work herein described. <br /> This application is made in compliancetwith nSanuJoaquin <br /> County Ordinance No, <br /> 1862 and the `Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 16251 N. Clements Rd.--i 8 Nj . /0 ranch ` <br /> CENSUS TRACT <br /> Owner's Name WES 'BREITENBUCHER bldgs <br /> . -- <br /> Address Phone <br /> 1625,1 N. Clements Rd. <br /> Contractor's NameCity' Lodi, F <br /> GOEHRING PUMP S< IRRIGATION, INC. <br /> License # 30903 phone 727-5548 <br /> r TY-PE=OFA-WORK -(-Che°ck-)-:�TEW�WEL-L4` ----p _ <br /> /I DEEPEN'/ /=-2-MECONDITIW`N /_/ `IIESTRUCTIOIV <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other /% PUMP REPLACEMENT /_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESS OPO L/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> -_ .Industrial Cable Tool CONSTRUCTION SPECIFICATIONS 3 <br /> Domestic/private Dia. of Well Excavation N <br /> Domestic --_ Drilled Dia. of Well Casing <br /> /public -__�____ Driven <br /> Irrigation Gauge of Casing <br /> Other Gravel Pack Depth of Grout Seal <br /> �—` Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> AYS <br /> / / State Work Done <br /> �-,_ rno <br /> elState Work Done Remodel from 25HP to 50HP__ _ added 20 & new <br /> DESTRUCTION OF WELL: Well Diameter _bawls `Peer eS=.PUMP�,w/Johns_ton.-par-fs- <br /> Describe Material and Procedure Approximate Depth <br /> ------------- <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health <br /> Ind the State of California pertaining to or regulating well construction. <br /> inter co District <br /> completion of my work on a new well, I will furnish the San Joaquin Localhin Health District a <br /> JELn <br /> DRILLERS PORT of the well and notify them before putting the well in use. The ab f <br /> matio ue to the best of my knowledge and belief. oveV r <br /> (DRAW PLOT PLAN ON REVERSETLE <br /> SID <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE Ii GROUT INSPECTION <br /> iSPECTION BY DATE PRASE III FINAN BY L INSPECTION <br /> CALL FOR A GROUT. INSPECTION PRIOR .TO GROUTING AND FINAL DATE 7 <br /> E H 1426 } <br /> ON. <br /> 7/71 1v <br />