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N/ <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR''OFFICE USE: ('j� 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14990 E. Prouty Rd. -- See map on reverseCENSUS TRACT <br /> • I <br /> Owner's Name FRANK CALOSSO Phone <br /> j <br /> Address Same as above City Galt <br /> Contractor's NameGOEHRTNG PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR ' PUMP REPLACEMENT /? <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 ' -1,Ir4t:' - -`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 />,. Other Information <br /> Disposal Other _ <br /> Geophysical Surface Seal Installed-B <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work :Done adding 20' to 100HP Smi thwa <br /> PUMP- REPAIR: State-Work Done -- <br /> t = s .... :. �; <br /> (DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> � I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rand 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 Burnish 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 /> informationis e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPEC ION <br /> PRIOR TO G AN A FINAL INSPECTION. <br /> SIGNED TITLE Sectv. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /, <br /> ADDITIONAL COMMENTS: p SE III/FINALINSPECTION <br /> PHASE 'II. GRO[JT INSPECTION <br /> INSPECTION BY e:= .' DATE INSPECTION BY E./ DATE 3 --I f• <br /> E H 1426 Rev. 1-74 __ <br />