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y <br /> 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 Joaquin <br /> County Ordinan a No. 18,52 an the Rules and Regulations of the San Joaquin Local Health District. <br /> J DRESS/LOCATION tMj. South of Collier on West/S Buck Rd. CENSUS TRACT <br /> .I� <br /> Owner's Name FRANK MONACO Phone <br /> Address _ <br /> P. O . Bax 639, Lockeford, . Ca. City <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br />-.TYPE OF WORK {Check)-:a NEW_W LL�/�/y;�D1.EPEN_/-7RECONDITION:/_7.. DES.TRUCT-IOiV-ION - ,---, _T. . <br /> PUMP INSTALLATION )& PUMP REPAIR / / PUMP REPLACEMENT /-7_ <br /> E <br /> Other / / " <br /> 11. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SiWAGE 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 I Rotary Type of Grout <br /> T Other Other Information <br /> IM� <br /> PUMP INSTALLATION: Contractor Sarre as above <br /> Type of Pump mP Johnston Turbine H.P. 50 <br /> PUMP REPLACEMENT: %, / State Work Done <br /> �I <br /> PUMP REPAIR: /k / State Work Done <br /> T <br />..- ESTRUCTION OF WELL: Well Diameter,- Well _ = ... __--;�... _- - == �Approximate.--Depth --. -. <br /> Describe Material and Procedure <br /> I hereby agree to comply' with all laws and regulations of the San Jo <br /> g again Local Health District � <br /> and the State -of California pertaining to or regulating .well construction,. Within FIFTEEN DAYS <br /> after completion of my Mork on a new-well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP T of .�the well and notify them before putting the well in use. The above <br /> informatio s 1de to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> it (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I. Z��A� DATE _ G <br /> ADDITIONAL COMMENTS: IM / �- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY II' DATE INSPECTION BY - - DATE 3 _ �g � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. _ <br /> E H 1426 a . <br /> 7/72 1M t <br />