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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. /_7151_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqui3 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION See reverse for map., CENSUS TRACT <br /> Owner's Name -FRANK CALOSSO _ - - —_ Phone <br /> Address 14990 E. Prouty Rd. City Galt <br /> Contractor'.a,Name GOEHRING PUMP' & IRRIGATION, INC . Lice_nse,#,. .309031Phone 727_5548 <br /> s <br /> —g—✓�— <br /> TYPE-OF-WORK(C4fe-ck) 64;o-NEW�WEi�L%=y-'DEEPEN s RUCTIo /� <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 ..,_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> k <br /> INTENDED USE TYPE OF WELL `.' CONSTRUCTION SPECIFICATIONS <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 /> Other Rotary Type of Grout <br /> Other Other. Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Johnston Turbine H.P. 100 <br /> PUMP REPLACEMENT: / / State Work Done.- <br /> PUMP <br /> one-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 District r <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> G 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 /> -informatio true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> 92,L <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE •,90.7�_-- _ <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION HAS-9 III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A'GROUT INS ECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 , 7172 1M <br />