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w - a l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <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 Joaquin <br /> County Ordinance No,. 1862 and the Rules and Regulations of the San Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION South side of Peltier R . , between; Thorht0h,CENSUS TRACT Ott( .13,(� <br /> h . <br /> Rd.- and 15 Phone ' <br /> Owner's Name NOVO-RF ADOS CONSTRUCTORS ti <br /> Address P. 0. Box 989, Chino, Calif. 91.710 City <br /> Contractor's Name GOEHRIIVG PUMP & IRRIGATION, INC. .License # 309O3lPhone 772``5548 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_7 RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION )0,' PUMP REPAIR /—/ PUMP REPLACEMENT fY <br /> Other <br /> 4 <br /> F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLT . �Ji, <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-'` '` f -'Gravel-Pack— ---Depth•-of Grout Seal <br /> Cathodic Protection Rotary Type, of=Grout v <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface,�Seal Installed B <br /> PUMP INSTALLATION: Contractor Goehring Pump H.P. ' IOHP <br /> f <br /> Type of Pump Pomona turbine <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Dona <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree. to comply <br /> with all laws and regulations of the San Joaquin Local Health istrict , <br /> I and .the State ;of- California -pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> ill furnish the San Joaquin Local Health Dtstrict a <br /> after completion of my work on a new well, I w <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i iq to the best of my knowledge and belief. I WILL CALL TOR A GROUT INSPECTION <br /> PRIOR TO GR ANVA ' 'INAL INSPECTION. <br /> SIGNEDAX <br /> ,. TITLE- <br /> A174 <br /> {DRAW:PLOT PLAN ON REVERSE 'SIDE} <br /> FOR DEPARTMENT. USE ONLY , <br /> PHASE DATE p2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE III/FINAL IN <br /> PHASE IZ GROUT INSPECTION SPECTIO <br /> ` INSPECTION BY DATE INSPECTION BY DATE 71illl <br /> : 1f77 " 2M <br />