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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. 2 ,a �p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s JJ <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/LOCATIONStock on t ee CENSUS TRACT psi 130-•07 <br /> Owner's Name N. H. GORDON Phone <br /> Address 728 Roper City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION License # 309031 Phone _727-5548 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_/ RECONDITION / /_7AL / DESTRUCTION / -� <br /> PUMP INSTLATION PUMP REPAIR /1 _PUMP REPLACEMENT <br /> Other /_7 <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.zof 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 _„- ---- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> adding new bowl to Pomona and changing <br /> PUMP REPAIR: X/ State Work Done HP from 15 to 25HP <br /> ESTRUCTION 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 s ue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G <br /> APPLICATION ACCEPTED BY DATE S �l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL_ INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DTE - 7 <br /> A � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />