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C.' B 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. ZZ-&2&� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -9;�� <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..11862. an'd. the Rules and Regulations of the San Joaquin Local Health District. <br /> 19 <br /> JOB�A DR SS LOCATION ° Peltier Road see reverse for ma CENSUS TRACT <br /> Owner's Name WALTER:s.�MOFFAT Phone <br /> Address • 'P. 'O.-.»Box 541A, u City Brentwood, Ca. <br /> Contractor's Name ' Goehring Pump & Irrigation, Inc. License 41 309031 Phone 727-5548 <br /> TYPF,, OF WORK (Check)-: -.NEW WELL`/ / DEEPEN %/ " RECONDITION'% / DESTRUCTION <br /> PUMP INSTALLATION /XY- PUMP REPAIR-/ / PUMP REPLACEMENT /7 <br /> Other` <br /> DISTANCE TO NEAREST: SEPTIC?. TANK SEWER LINES PIT PRIVY <br /> SEWAGEtDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY -LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cl <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ( Drilled Dia. of Well Casing \ <br /> IF _ _ Domestic/public I Driven Gauge of Casing, <br /> �_ IrrigaCion "� -Gz`avel. Pacic­ ,< e th of Grout Sear <br /> TCa.thadi.c.Pro_tection,Y.1- '- �Rot�ary_. Type of--Grout.- - <br /> Disposal 1 Other� . Other Information °Y <br /> E Geophysical ';Surface Seal Installed By: ^ <br /> PUMP INSTALLATION: " Contractor G_oehring Pump '& irrigation, Inc. <br /> 4 iT e of Pum H.P. <br /> YP p Johnston TtirbinP 60HP <br /> iPUMP REPLACEMENT: / / State Work Done <br /> ` PUMP °REPAIR: , /-/—State-Work, <br /> IRES•TRUCTION "OF "WELZ ""'Well, iamete�r . s Appro'x ma e' Depth <br /> k <br /> De'scr:L)b4e *-t-'erial and Procedure' <br /> 1 <br /> � I hereby agree to-..;comply with,all laws and regulations of -the- San Joaquin Local Health District <br /> and the State of, California.,pertAning to or regulating well construction. Within FIFTEEN .DAYS <br /> kafter 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 put�ing�tkie-wW6rl-iii use. `-The above" <br /> : information is true to,-the-be-s-t-of- my knowledge. and".be]def W.IJ.I-GALL- FOR A-GROUT ,.IN.SPECTION <br /> ;PRIOR TGL GROUT <br /> ING,AND i FINAL, INSPECTION. <br /> SIGNED -- TITLE <br /> * :� � • »� :i (DRAW PLOT PLAN ON REVERSE SIDE) ti ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��% ? i�. DATE <br /> ADDITIONAL.—COMMENTS: <br /> PHASE II eOUT INSPECTION PHASE III/FINAL INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY DATE ' S <br /> E H -142.6: ..Rev. l-74%,- w . _ '�. 1177 . 2M <br />