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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. ;7,-.,- <br /> THIS PERMIT <br /> ,-.,-THISPERMIT 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 Joaquii <br /> County Ordinance No. 1862' and the 'Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14831 E . Collier Rd. -- in and CENSUS. TRACT <br /> Owner's Name GEORGE `FRANKE- Phone <br /> Address 14831 E. Collier Rd. City Acamoo <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> TYP-E.z_OF:..WORK_,(Check):---NEW-WELL-/:;T—DEEPEN/_-7--RECONDITION—/_�-.- DESTRUCTION /7'"" — <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT :&T <br /> ` Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: )6Y State Work DoneChanged from 7-,HP to 15HP Myers Submersible <br /> PUMP REPAIR: / J State Work Done <br /> DESTRUCTION 4F WELL:­6 Well-Diameter r 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 rue -to the best of my knowledge and belief. <br /> SIGNED L TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 1 APPLICATION ACCEPTED BY DATES L <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a2_--, DATE <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. / <br /> E H 1426 7/72 1M <br />