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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. <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 Joaquil <br /> County Ordinainee.No._1862 and the Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Southwest Corner of Collier & Elliott Rds.CENSUS TRACT <br /> Owner's, Name GOEHRING~FARMS Phone <br /> Address 13989 N. Curry Lane _ _ City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION,- INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check): NEW WELL / T DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ , <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> r <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 <br /> Irrigation _�_-_..._... _ Gravel Pack-- Depth-of-Grout---Seal <br /> Other- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump s Turbine - irriaation H.P. 25 <br /> ! PUMP REPLACEMENT: / State Work Done removed 15HP & replaced with 25HP <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 ue to the best of my knowledge and belief. <br /> SIGNED TITLE J&,7,eZ7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1 g <br /> APPLICATION ACCEPTED BY DATE 7 o' ;� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIi FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �p DATE 0-,12 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> t E H 1426 7/72 1M <br />