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- , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: fig v1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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 12686 N Curry Rd., CENSUS TRACT <br /> Owner's Name nwa i e Nash Phone _ <br /> Address 12686 N. Curry Rd. City Lodi <br /> Contractor's Name GOEHRING PtTMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> j TYPE OF WORK (Check) : NEWWELL�%�� DEEPEN/�/ RECONDITION /_7 DESTRUCTION / 7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT I�T <br /> Other <br /> t 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 I � Dia. of Well Casing � <br /> Domestic/public Driven .. .�,, Gauge of Casing m <br /> Irrigation Gravel Pack ' . Depth of Grout Seal `@v� <br /> Other Rotary i Type of Grout <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor — Same as above <br /> Type of Pump Tu b'ne - itri t'on H.P. 15 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: +L State Work Done removed 7� HP and installed 15HP aloe with <br /> - T some repair & alternat olm <br /> ESTRUCTION 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 /> Land 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;is.)true the best of my kn.owledge and belief. <br /> TITLE <br /> SIGNED <br /> {DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE "dt�-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL-_INSPECTION" <br /> INSPECTION BY _ DATE INSPECTION BY Ct!:2� DATE <br /> CALL FOR A.GROUT..INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br />