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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. zz- 1 � <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 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 20396 N. Dustin Rd. <br /> CENSUS TRACT <br /> Owner's Name J. M. TOSH <br /> Phone <br /> Address 20396 N. Dustin Rd. <br /> City <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check):. NEW. WELL-/-_ DEEPEN / _/ RECONDITION- /77---DESTRUCTION, /-] <br /> PUMP INSTALLATION PUMP REPAIR AD 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 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 S <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: / / State Work Done <br /> PUMP REPAIR: )aEF State Work Done Chan ed from 10 to 15HP Pomona, rewired & <br /> ESTRUCTION OF WELL: Well Diameter added 20* column <br /> Describe Material and Procedure Approximate Depth <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 i ue to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br />'RASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY 5221 DATE (� <br /> IDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL DATE !_.�._ � �INSPECTION_ <br /> 7 <br />;NSPECTION BY DATE INSPECTION BY �" <br /> � _ _ ' 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />