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( SAN JOAQUIN LOCAL HEALTH DISTRICT <br />-F—Or,-­OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Jl- 14 S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L IO-Ob7 <br /> (Complete In Triplicate) <br /> Application is hereby-made ��o 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 f <br /> County Ordinance No., 1'862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !i830;3 N. Hwy. 88 <br /> CENSUS TRACT <br /> Owner's Name TED ORGARD, Phone <br /> Address Same as above i�[ <br /> City Lockeford <br /> Contractor's Name GOEHRIPNG PUMP & IRRIGATION, INC. License # 309O3lPhone 727-5548 <br /> TYPE OF WORK (Check) ; NEW (WELL I / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUM INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT �J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r <br /> I�SEWAG,,E DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPE! TY 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �\ <br /> I� Cathodic Protection Rotary Type. of Grout 1� <br />` Disposal Other Other Information <br /> Geophysical q Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump Myers subme sible H.P. 2 <br /> PUMP REPLACEMENT: /X}( S tate Work Done e ] Cedwith new. 9HP M)ZPr-q <br /> i <br /> ji <br /> PUMP .REPAIR; /' /'� State Work`Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 /> iWELL <br /> after completion of my 'worI. on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT'of' the well and notify them before putting the well. in use. The above <br /> 'PRIOR <br /> is tr t thelbes.t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT INSPECTION. <br /> ISIGNED TITLE _ S rt v. <br /> �M f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED , Y d DATE _?7 <br /> ADDITIONAL COMMENTS: I � f <br /> PHASE II6GROUT INSPECTION INSPECTION <br /> III/FINAL TNSFECT ON <br /> 'INSPECTION BY 1� DATE INSPECTION BY DATE <br /> �, ��- 11.77 - 2M <br />