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� SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR OFFICE U 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7$—q'911 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 FAIE'tlll�:;: . • seemap on reverse CENSUS TRACT 05-3 -040-03 <br /> Owner's Name Arend Van Gaalen Phone <br /> Address 15843 N. Tully Rd. City Lodi <br /> Contractor's Name Goehring PUMD & Irri ation Inc. ,.License # 309031 Phone ' 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL '/_7 DEEPEN /_7 RECONDITION /77 DESTRUCTION /_7 <br /> PUMP INSTALLATION )tX/ PUMP REPAIR L/ ePUMP REPLACEMENT /_7 Q} . <br /> Other /7 <br /> DISTANCE TO NEAREST: _SEPTIC TANK SEWER LINES PIT PRIVY <br /> (SEWAGE DISPOSAL FIELD CESSPO_0L7SEEPAGE PIT OTHER <br /> �-PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL�� <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 /> Cathodic Protection Rotary Type- of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Goehr-j ng 2=2 <br /> Type of Pump __ Myers submersible ._-- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP -.REPAIR: /% State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter _ _ - Approximate Depth ' <br /> Describe Material and Procedure <br /> -- <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 REPOIT of the well and notify them before putting the .well in use. The above <br /> information to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR ANRPA FINAL INSPECTION. <br /> SIGNED TITLE <br /> 4 <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GF <br /> OUT INSPECTION PHASE IAI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DOTE 7- J z- 7 <br /> E H'1426 Rev. 1-74 �J �/7� 2M <br />