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T ti <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 (J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date,Issue� ��: <br /> (Complete In Triplicate) <br /> Application is tereby 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 Joaquip: <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 10663 Hwy. 88-- See reverse for map CENSUS TRACT <br /> Owner's Name MATT WARD Phone <br /> Address 1959 - Sonoma Street City ' ' Stockton <br /> Contractor's Name Goehring Pump & Irrigation, Inc. .License # 309031 Phone '727--5548 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RE-CONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> 'Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/privateDrille.d___ a._ of-Wel 1..Casing._..._ _ _T <br /> Domestic/public T Driven GDi.auge of Casing . <br /> irrigationll`� "� '"' -'Gravel-Pack-�""+ both-of-Grout-Seal <br /> Cathodic Protection T Rotary _Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - ti-r--- --- =„_� -,Y,; H.P. . . . <br /> PUMP REPLACEMENT: / State Work Done install 3 HP item sub,. in _a_wpl 1 tha t ha <br /> _ beeri. 'recased. <br />- PUMP .REPAIR: State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter __i f Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health. . igtrict <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 ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G.WG A FINAL INSPECTION. - <br /> SIGNED TITLE �. <br /> (DRAW PLOT PLAN ON REVERSE SIDE)° <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D <br /> APPLICATION ACCEPTED BY j DATE e;_7" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE & � <br /> E H 1426 Rev. 1-74 <br />