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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _21A & <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 '7 <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. . I <br /> JOB ADDRESS/LOCATION 14990 E. PrOut Rd. --See reverse for map CENSUS TRACT ! <br /> I <br /> Owner's Name FRANK CALOSSO Phone <br /> I <br /> Address Same as above City Galt <br /> Contractor's Name GOEHRING PUMP & IRRIGATION,• INC-. -License # 309031 Phone 727-5548 <br /> of- ._. _ _ y =— L - - _�� 4r=_: <br /> TYPEy WORK (Check) , NEW�'WELL �J DEEPEN_ / /�RECONDITI_01V• _/_f^DESTRUCTION /? <br /> PUMP INSTALLATION /�.J PUMP REPAIR / . PUMP REPLACEMENT` /7 t <br /> Other / / - "-- ,.: . ,� x ,.- I <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 j <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 >r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal_ _Ins"talled By: <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: {/ State Work Done.are adding 20-t--. to _100HP. Pomona _ .. <br /> i <br /> I <br />)ES;TRUCTION OF WELL: Well Diameter Approg imate Depth <br /> Describe Material and Procedure ° <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 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 /> JELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TOG A FINAL INSPECTION. <br /> iIGNED TITLE segtyt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />"RASE I , <br /> APPLICATION ACCEPTED BY , �. DATE <br /> MDITIONAL COMMENTS: ' <br /> PHASE II' GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY j" .'. DATE INSPECTION BY /'� DATE 3 <br /> z <br /> E H 1426 Rev. 1-74 1/77 2M <br />