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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 -_T <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 2eandnthesRul sdandThis Regulationstofnis the SaneJoaquinpL calewith HealthSan Joaquin <br /> District. <br /> County Ordinance No. 186 <br /> JOB ADDRESS/LOCATION 21199 N. Trethwa Road CENSUS TRACT <br /> Owner's Name Ries McKee Phone <br /> Address Same as above City Acam <br /> Contractor's Name GOEHRING PUMP & IRRIGA'T'ION, INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check): NEW-WELL / / DEEPEN / RECONDITION / 7 DESTRUCTION /_T <br /> F PUMP INSTALLATION / / PUMP REPAIR a—PUMP REPLACEMENT /_7 <br /> Other / _/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> 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 V <br /> - Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done Pull 1;HP submersible pum and determine why_ <br /> A = I motor doe's•t run <br /> ,PESTRUCTION 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 <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> lafter 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 /> informationue to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 2 <br /> PHASE I <br /> 1APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: / PHASE III FINAL I SPEC I N <br /> PHASE II G 453 INSPECTION DATE 7 <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />