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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE 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 Date Issued_"� -%r( <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. <br /> JOB ADDRESS/LOCATION 16051 N. Alloine Rd. CENSUS TRACT <br /> Owner's Name Arnold Knoll Phone <br /> Address 7900 E. Realty Rd. , City Lodi <br /> Contractor's Name Goehring Pump & Irrigation, Inc. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL 16V--DEE- / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLAT 0 7PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER - <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C.. <br /> Industrial Cable Tool Dia, of Well Excavation +� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump Myers submersible H.P. l <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION 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 bistrict <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 i t <br /> to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO D •A FINAL INSPECTION. <br /> SIGNED TITLE a <br /> Al (DRAW PLOT PLAN ON REVERSE SIDE) '�e ✓ -._'_____ � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��, F, DATE 21 <br /> ADDITIONAL COMMENTS: —"— <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �rz 19--J,177 ' .- <br /> 2M <br />