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` xSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFIGE USE: . 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application 'is Hereby made to the San (Joaquin COMPleeLo alIn rHealthtDistri <br /> ct a permit <br /> and/or install the -work herein described. This application is made inrcompliance twith. SanuJoaqul <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5098 N. H 88 <br /> CENSUS TRACT <br /> Owner's Name TUCKER 'BARTH <br /> Phone <br /> Address P. O. -Box 827 <br /> City Clements <br /> Contractor's Name Goehrincr Pump & Irrigation, Inc. License # 3C79031Phone 727-5548 <br /> 3090 - <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /? t <br /> Other / / PUMP REPLACEMENT N <br /> a 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT a' <br /> `.. OTHER - <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 <br /> �; <br /> INTENDED USE k2TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIgNS <br /> fir';. Cable Tool Dia. of Well Excavatio <br /> Domestic/private ` Drilled n �p� <br /> Domestic/publicDia. of Well Casing <br />�w `--j.,,Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectionary <br /> W41Typeof Grout <br /> Disposal Other-. Other Information f <br /> Geophysical Surface Seal Installed B <br />•_ ;. _.. {, � _ Y - <br />?UMP INSTALLATION: Contractor <br /> Type of Pump : <br /> �-H.P. <br />'UMP REPLACEMENT: <br /> / State Work-Done, r laced LOP Jet 12UMPw 3HP M Vers sub. <br />'UMP .REPAIR: L- ' <br /> Std Work Done,` <br /> .rte': <br /> ES-TRUCTION OF WELL: Well Diameter' I <br /> . Describe Material. and Procedure° ---� kpproxi%ate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Locg3 HealthNi-strict f <br /> nd the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS F <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local. Health District a <br /> ELL .DR44:: <br /> PORT of the well and notify them before putting. the..we11 in use. The above <br /> nform the best of my knowledge and belief. I WILL CALL FOR A-GROUT INSPECTION 'IOR TA FINAL INSPECTION.IGNEDs <br /> IdL TITLE <br /> DRAW PLOT,.PLAN,ON REVERSE SIDE <br /> f <br /> -FOR-DEPART NT.,USE ONLY <br /> VASE I <br /> PPLICATION ACCEPTED BY } ' <br />]DITIONAL COMMENTS;a; ,� _ DATE <br /> - ._._ <br /> iPHASE �� GROUT. INSPECTION <br /> JSPEGTION BY PHASE _L11 FINAL INSPECT ON <br /> DATE INSPECTION BY DATE <br /> E H�1426 Rev., 1-74 —%r1PM 4 <br />