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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �,Sr j <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued �� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> r. <br /> JOB ADDRESS/LOCATION 12686 N. Curry Rd. CENSUS TRACT <br /> Owner's Name DWAYNE D. NASH DDS Phone <br />.Address 1.2686 N. Curry Rd � City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 30903 . Phone 727-5548 i. <br /> E <br /> TYPE_,OF.,WORK.. (Check--)-:­,NEW-WELL_/�/ DEEPENS/- /PRECONDITION—/717-- DEST-RUC-TI0N F/::77-----_ --- -�. J <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other.,/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE fDISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE lerPRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial ' r T Cable-Tool Dia. of Well Excavation <br /> F Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> I Irrigation •-Gravel Pack----•- .-Depth-.•of_Gr.ou-t Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ° 0then. ;�� 0_ther. Information <br /> Geophysical ' Surface Seal Installed B <br />(PUMP INSTALLATION: Contractor' <br />(( x,t :_ x�_��,x.:;� H.P. <br /> Type of Pui��:.,'s��.k-,�-.._� �.._�:i�., <br /> 1 PUMP REPLACEMENT: S tate•Work Done ed 3HP Berkeley- wi th, 7 2H�jZe.rs_ <br /> _ submei-sible <br />,PUMP -.REPAIR: / / State Work Done ! <br />�DESTRUCTION OF WELL: tiLL,Well Diameter; : _-- - r _ - _ `fApproximate Depth_ n <br /> Describe Material and Proceo.ur-e <br />:I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand 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 /> SWELL DRILLER9s`-_REPORT'•of tt e-well 'ah''A'tify them before putting the well in use. The above <br /> !information is true toit-hebest, of:,my:knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA INA , INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1PHASE <br /> FOR DEPARTMENT USE ONLY <br /> I DATE �� 7 <br /> 1APPLICATION ACCEPTED BY <br /> ,ADDITIONAL COMMENTS: <br /> -.PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE -.� ^7. <br /> r <br /> _ .. 1177 _ . 2M <br /> E H 1426 Rev. 1-74 <br />