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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 /> f S i i� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> q <br /> Pextnitallo!: <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedD {; <br /> p (Complete In Triplicate) <br /> Application is`$ereby made to the Sax 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 o"f the San Joaquin Local Heath: District. <br /> JOB ADDRESS/LOCATION 15953 E Smith Road CENSUSTRACT # <br /> Owner's Name LEO WHITMAN Phone r <br /> Address 15953 E . -Smith Road City' Lodi. ' <br /> Contractor's Name G,OEHRING PUMP & IRRIGATION, INC . License # 309031.Phone 727-5548 <br /> _. (Check) : -- ---.-._.... _ ,.-•- ,. _,. i <br /> TYPE OF WORK ( k) : NEW WELL / / DEEPEN /7. RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Xk7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !ter PIT PRIVY..., 1 <br /> SEWAGE DISPOSAL FIELD""`""" 'CESSPOOL/REEVlAOt 'PITS`-'"`OTUR <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL FCONSTRUCTION SPECIFICATIONS ' <br /> Industrial 1i Cable Tool Dia.' ofxWell 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' �Lotary Type of Grout <br /> Disposal — Other. Othe'r, Iftformation <br /> Geophysical Surface.!Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Ty,pe of Pump :► = H.P. <br /> PUMP REPLACEMENT: /y, State,Work Done •;pulled 5HP turbinQ,_, iLotalled _.lg�LPrs <br /> submersible ! <br /> RUMP_. REPAIR: ". /--r/ State Work Done -- Y_ --j <br /> DESTRUCTION OF WELL: Well Diameter € Approximate Depth ' <br /> -� Delscribe Material and Procedure # t <br /> I hereby agree to comply <br /> awith all laws and regulations of the San Joaquin Local Healthbistxict <br /> and the State of California pertaining to or regulatingjweil "construction: Within FIFTEEN DAYS p <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 beforeputting. the. well in use. The above <br /> informatio ue to the best of. my .knowledge and belief! I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G 4AD A FINAL INSPECTION. <br /> SIGNED n_W.__--- P-___.. �..�. ..TITLE7.. <br /> (DW_ LOT_P.LA , O _RESESbE __wR -r r-•,-.-- <br /> is FOR DEPARTMENT USE ONLY <br /> PHASE I 4 <br /> APPLICATION' ACCEPTED BY DATE ZZLr <br /> ADDITIONAL COMMENTS: <br /> PHASE " I GROUT INSPECTION PHASE I /FINAL INSPECTION. <br /> INSPECTIONBX DATE INSPECTION BY DATE ' 7' <br /> :. <br /> E H 1426 Rev. 1-74 <br />