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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ° 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) "466--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2.:6 9iD <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued 6 <br /> (Complete In Triplicate) <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: 1.862 and the Rules and Regulations of the San Joaquin' Local Health District. <br /> J 18879' N, Clements Rd. <br /> OB ADDRESS/LOCATION <br /> 0 M' N 0 Brandt Rd. W 0 Clements Rd. CENSUS TRACT <br /> F <br /> Owner's Name JOHN WHITBY' - Phone <br /> k <br /> Address 1.8879 N. Clements Rd. City. Lodi <br /> Contractor's .Name GOEHRING PUMP & IRRIGATION, INC. License # 309O3lPhone727-5548 <br /> TYPE OF WORK.r(Check): NEW <br /> WELL. / mayDEEP_ENL/�/.�ItECONDI.T..I.QN:_/ �DESTRU.CTION�/ <br /> PUMP INSTALLATION AD� PUMP REPAIR / / PUMP REPLACEMENT /7 <br />! Other /_7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION.- Contractor Same as above r <br /> Type of Pump U.S. Pum Turbine H.P. 2 HP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 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 rue to the best of my knowledge and belief. YJ <br /> SIGNED TITLE 5 <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY J DATE 2,0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION V F SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4« - DATE /;L - ' 7? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND -FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />