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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17- <br /> THIS <br /> 7-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 See map on reverse-12042 N. Alpine Rd. CENSUS TRACT <br /> Owner's Name pETE VAN STYN Phone <br /> Address 12042 N. Alpine Rd. City <br /> Contractor's Name ' GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> L <br /> TYPE OF WORK (Check) NEW WELL L/ DEEPEN :/ / RECONDITION /_/ - REPLACEMENT <br /> PUMP INSTALLATION P <br /> _ / UMP REPAIR /� PUMP REEMENT <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 <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 <br /> Geophysical Surface Seal -Installed By: �3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT: �`�` <br /> State Work Do ;e..Fiaeed exi.stina 15HP with 25HP used Layne <br />?UMP .REPAIR: / / State Work Done <br />)ES�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 /> if ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br /> Lnformation is to the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br />'RIOR TOG AN A FINAL INSPECTION. <br />'IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?RASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIZ FINAL INSPECTION <br /> INSPECTION BY M JjQ DATE INSPECTION BY — DATE ZA•A-77. , <br /> E H 1426 Rev. 1-74 1127, 2M <br />