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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) Ot3- 12-o -515 <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. <br /> JOB ADDRESS/LOCATION SEE MAP ON REVERSE �IA�QC7G�' -4 iGo2 C� CENSUS TRACT <br /> • I <br /> Owner's Name FAIRWAY ESTATES Phone <br /> Address .1330 E. Fairmont Avenue City _Lodi <br /> Contractor's Name Goehrin Pum & -kri ation License # 309031 Phone 1 Inc. -5548 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/' / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / /�PUMP REPAIR / / PUMP REPLACEMENT /_7 a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, ;r,_. PIT PRIVY ij^l I� <br /> SEWAGE DISPOSAL FIELD 11C•ESSPOOL-/SEEPAGE PIT OTHER <br /> ..:. <br /> PROPERTY LINE - PRIVATE�DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r"" ; lCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.,o Tell Excavation <br /> Domestic/private Drilled Dia.gbf ,Well Casing <br /> Domestic/public... "A r.r .. -Driven , Gauge of Casing <br /> Irrigation Gravel�`Pacic--__ Depth�of 45rout Seal <br /> Cathodic-Protection— '-`- �---Rotary- -Type-of-�Grouty ��s <br /> Disposal Other + Other Information <br /> Geophysical Surface Seal Installed By- _ <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Y-f <br /> — <br /> "PUMP"-REPAIR:"" - / /-" State Work Done <br /> Top of ground; casing cut orf. ' _T3oft.`DESTRUCTION OF WELL: Well Diameter 14" & 12'• Approximate Depth12"- 9 <br /> 2 Wells Describe Material and Procedure will fill ' t <br /> until 50' of top of rnd- bal. with concrete to ' <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 regul Le( nstruction. 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 not'i'fy them before putting the wellin use. The above <br /> information e to the best of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> '.PRIOR TO A FINAL INSPECTION. <br /> SIGNED [ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ,BY ' DATE 0_�"7 <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III/FIN NSPECTION <br /> 71 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r• E H 1426 Rev. 1-74 <br />