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C,1 Se—)JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1641 r , Hazelton Ave. , Stockton, Calm . <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. AVP <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7 <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 18303 N. Hwy. 88 CENSUS TRACT <br /> Owner's Name TED MRGARD Phone <br /> Address Same as above City Lockeford. <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 309031Phone 727--5548 <br /> rYPE OF WORK (Check) : NEW WELL J / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT—X67 <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 /> IN USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial. Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <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 .B <br /> PUMP INSTALLATION: Contractor Same as above <br /> Type of Pump MyeraH.P. 2 <br /> PUMP REPLACEMENT: . / State Work Done replaced 1 aJE! jet pup with n(-w,2T-TP MyprS <br /> PUMP -.REPAIR: / / State Work Done <br />)ES�TRUCTION 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 is true- o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUT A INAL INSPECTION. <br /> SIGNED TITLE _ Secty. -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> XPPLICATION ACCEPTED BY Z�; DATE <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1.177 nnr <br />