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9 �OAQUIN LOCAL HEALTH FOk DISTRICT <br /> OFFICE USE: 166 Hazelton Ave. , ,Stockton, Ca - <br /> Telephone: (209) 466--6781 �J <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 egnstruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquip <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 10653 Hwy. 88-- See reverse for map CENSUS TRACT <br /> Owner's Name MATT WARD Phone <br /> Address 1959 Sonoma Street City Stockton <br /> Contractor's Name Goehring Pump & Irrigation, Inc. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN/ / RECONDITION / / DESTRUCTION / ,. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEW4GE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <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 p� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B Ocj <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; State Work Done inFtall 3 HP Myers SUb,• in..D ._yml ] a.at- ha�� <br /> been recased. <br /> PUMP �REPAIR: / / State Work Done <br /> DESTRUCTION 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 Healtb biptrict . <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 ue to the best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TO G G 'b A FINAL INSPECTION. <br /> SIGNED- TITLE <br /> (DRAW PLOT PLAN ON REVERSE S IDE -�--- -'— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT_ INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> D '2_7 / ;977 _ 2M <br />