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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4bb-67$1 M <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 See reverse _tor' map CENSUS TRACT <br /> Owner's Name WATTS APIARIES Phone <br /> Address 9808 E. Hwy. 12, Lodi, Calif. City <br /> Contractor's NameQ fru jr �E �"�'�� y� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /—f DEEPEN RECONDITION /-T DESTRUCTION /_ <br /> PUMP INSTALLATION /T /PUMP REPAIR / / PUMP REPLACEMENT ff <br /> Other / / <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 /> Q <br /> Industrial Cable-Tool Dia.-of-Well Excavation- <br /> Domestic/private Drilled_ Dia. of Well Casing_ <br /> Domestic/public v_ I3riven 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 Goehrign rump & Irrigation, Inc. <br /> I� <br /> Type of Pump harbine _ jirigationH.P. 25 <br /> PUMP REPLACEMENT: // State Work Done removed 15HP pump and replaced it with -_ <br /> _ 25- HP turbine <br /> PUMP REPAIR: / / State Work Done <br /> r ,PESTRUCTION_ 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 4 <br /> after completion of my work on a new well, I will 'furnish the San Joaquin Local Health Distriet a <br />� WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />� informatioa i rue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDErLE4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY ��.�/� �1 ____ __ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />