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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L- <br /> Jgx <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dste Issued , S' <br /> (Complete In Triplicate) <br /> Application .is tereby 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 Distrix t. <br /> JOB ADDRESS/LOCATIOM.Brandt Rd. (See reverse) CENSUS TRACT <br /> Owner'.s Name HenryBi schel Phone <br /> Address 11701 E. Brandt Rd. City Lockeford <br /> Contractor's Name Goehring Pumi2 & Irri ation Inc. License # 309031 Phone ' 727-5548. <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/%` RECONDITION /77, DESTRUCTION /_7 <br /> PUMP .INSTALLATION / / PUMP REP :UMP REPLACEMENT /_7 <br /> Otter �j�/ .. . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT -PRIVY <br /> SEWAGE DISPOSAL'•- FIELD CESSPOOL/SEERAGE PIT, OTHER <br /> PROPERTY LINE -_PRIVATE DOMESTIC WELL "PUBLIC DOMESTIC WELL <br /> INTENDED' USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable'-Tool Dia, of Well Excavation <br /> Domestic/private Drilled `t Dia. of Well Casing' <br /> Domestic/public Driven" Gauge of Casing _ <br /> Irrigation Gravel'3.Pack Depth of Grout Seal-- <br /> - <br /> Cathodic Protection _ _ _ _Rotary 1 T e of�Grout` <br /> Disposal .f7 6—the-rO.ther� Informatian--), I <br /> Geophysical �-7-----Surface--Seal-Ins-talled-B <br /> PUMP INSTALLATION: Contractor `S <br /> Type of Pump H.P. . . . <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP .REPAIR: - - T State 'Work Done Pull iOHP Porimbna'" -i�e cidl-'bowlsY ad`ci�30"'"�& <br /> change to 15HP <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 istrict <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN PAYS <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 abode'. <br /> information4M46A <br /> to the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION . <br /> PRIOR TO GR FINAL INSPECTION. <br /> SIGNED TITLEJ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I? <br /> APPLICATION ACCEPTED BY G DATE �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> f. <br /> E H 1426f . <br /> Rev. 1-74 77 2M <br /> �� - <br />