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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-,4,t6 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A ��,L <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 1 Mi . South of Hwy. 12 on West side Fox Rd.CENSUS TRACT <br /> Owner's Name TRIPPLE OAKS DAIRY Phone <br /> Address 16630 N. Tretheway Rd. City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, _INC_. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL /-T DEEPEN /-7 RECONDITION /-7 DESTRUCTION /'7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR /—/ PUMP REPLACEMENT /?X7 <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 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 <br /> Other Rotary Type of Grout <br /> Other ' Other Information <br /> PUMP INSTALLATION: Contractor Same s above <br /> Type of Pump Turbine - irriaation H.P. 25 <br /> PUMP REPLACEMENT: / State Work bone removed 15HP turbine - installed new 25HP <br /> `_ -- turbine <br /> PUMP REPAIR: / / State Work Done <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 /> 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 putting the well in use. The above <br /> information istrue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDkT- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY ��,, �r DATE "I.- -77 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �'3DATE -5-/J <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION: <br /> E H 1426 7/72 1M <br />