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0/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -70—r--''OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?-760 P <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 const uct <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 1-7446-5 E. Hyy. 88--new home being constructQINSUS TRACT <br /> I <br /> Owner's Name REUBEN GOEHRING Phone <br /> between <br /> Address 1.7065 E. Hwy. 88 Ci.tyLockeforgr <br /> Contractor's Name . GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /�/ DESTRUCTION /_7 <br /> PUMP INSTALLATION ]kX/ PUMP REPAIR/ / PUMP REPLACEMENT /_7 <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 <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing � . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information I <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump Myers submersible H.P. 3 <br /> PUMP REPLACEMENT: � ? <br /> / / State Work Done <br /> _ I <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION 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 is true the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A AL INSPECTION. <br /> SIGNED TITLE Secty. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYv l <br /> �� � � ,� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROAT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY U DATE `` Z <br /> E H 1426 Rev. 1-74 1 Z7 - 2M <br />