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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. A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;� •7'� <br /> (Complete In Triplicate) <br /> Application is hereby m' ade' 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 r <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 13Z�-i <br /> JOB ADDRESS/LOCATION 1-3949 N. Curry Rd. - in yard CENSUS TRACT <br /> - I <br /> x <br /> Owner's Name GOEHRING FARMS Phone <br /> Address 13989 N. Curry Rd. City Lodi <br /> Contraotox"'s Name. .GOEHR.ING. PUMP,. &. IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK .(.Check).:_,-NEW WELL ./�­DEEPEN"'/ /'PRECONDITION j-/-: :DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT _ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dias of Well Excava-t-ion C <br /> Domestic/private Drilled Dia. of Well Casitn.g..,,; <br /> _ _.Domestic/public.� =Driven ;•.-''Gau'ge Fof Casing ' _ . , _ _. - <br /> Irrigation Gravel Pack Depfh of Grout Seal. <br /> Cathodic Protection Rotary Type' of Grout i . <br /> Disposal Other Other Information'` 1'5_ <br /> Geophysical Surf acee=Se7al Installed By: <br /> PUMP INSTALLATION: Contractor r� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /X State Work Done replaced existing hitt P - , <br /> _ mersible' --y- <br /> PUMP REPAIR: / / State Work Doiie. �r�, " �A-/_ <br /> DESTRUCTION OF WELL: Well Diameter i4 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'cons.truction. Within FIFTEEN DAYS 1 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO CA87NNG AND A FINAL INSPECTION. `r <br /> SIGNED TITEE <br /> (DRAW PLOT PLAN ON REVERSE SIDeZ4 <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-.2-i ',7 -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> . 2M <br /> E H 1426 Rev. 1-74 <br />