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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR <br /> OFFICE USE: �/� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466•-6781 Permit No. �r`{� 'h <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT `lr <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued qW <br /> (Complete In Triplicate) r. <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 /> f <br /> JOB ADDRESS/LOCATION 22733 E. Buena Vista Rd.--in garage CENSUS TRACT <br /> Owner's Name JERRY JUENCHE Phone <br /> City Clements, Ca. <br /> Address: Same as above <br /> Contractor's Name GDEHRING PUMP & IRRIGATION, INC. License # 30903IPhone727-554$ } <br /> c <br /> f � <br /> 1 TYPE OF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION_/ / DESTRUCTION <br /> I <br /> PUMP INSTALLATION /X PUMP REPAIR PUMP REPLACEMENT I T <br /> 4 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 v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation ( `W <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' g Rotary Cathodic Protection Y TYPe of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Same as above H.P. 5 <br /> l Type of Pump Myers submersible <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-iiEPAIR / / State Work' Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> F; I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of-the well and notify them before putting the well in use. The above <br /> information i to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GR, D A FINAL INSPECTION. <br /> SIGNE <br /> C D <br /> TITLE e <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> IPHASE I <br /> DATE b <br /> APPLICATION ACCEPTED -BY.(-. <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION . DATE O' 7�_ <br /> INSPECTION BY DATE INSPECTION BY fjC? <br /> a .. l 7 7.7 _ 2M <br />