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5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: ' :1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I` . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/� <br /> (Complete In Triplicate) <br /> Application is G reby 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 Joaqu*n <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin.Local Health District: <br /> F <br /> JOB ADDRESS/LOCATION 3- Mi. .South of Sargent Rd. ; 30' East oct on CENSUS TRACT 4S'3— G�fD2 <br /> fsr3Zack'Tdne -Rd. <br /> Owner's Name' JAN WARNERDAM Phone <br /> Address 16138- N. Jack Tone Rd. City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC . License U 309031 Phone ' 727_6648 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION` /? DESTRUCTION /? ' <br /> PUMP INSTALLATION PUMP REPAIR/ PUMP REPLACEMENT /-7 +� <br /> - Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Y SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial t Cable Tool Dia. of-Well Excavation <br /> Domestic/private Drilled Dia. of- Well Casing " <br /> Domes-t-ic/public Driven Gauge of-Casing <br /> Irrigation Gravel Pack Depth of -.Grout Seal <br /> `Cathodic Protection Rotary Type of- Grout <br /> Disposal Other Other Iiafoimation <br /> Geophysical ---^- --- _ <br /> _ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump turbine H.P. 5t <br /> PUMP REPLACEMENT. / / State Work Done <br /> "PUMP"REPAIR;'." -- <br /> -'� ate Work Done regal rs `to,_;foot- valve =-; - <br /> .-s� ..�; <br /> PES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ^� Describe Material and Procedure <br /> Thereby agree to comply with all Laws and regulations of the San Joaquin Local Health istriat <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 /> WELL DRILLERS REPORT of the well and notify them before puttingthewell 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 D A FINAL INSPECTION. <br /> SIGNED' TITLE ! <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY . � <br /> PHASE I <br /> i t e. S� 'L 1 <br /> 8� <br /> ._ <br /> APPLICATION ACCEPTED ,gY;l w DATE ' �2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU INSPECTION PHASE III/FINA.L "INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - / -7: <br /> i j, <br /> 77 <br /> E H 1426 Rev. 1-74 r/�7 - i <br />