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SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. V y <br /> j Telephone (209) 466-6781 FILE <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION • -.��••••"r-r.� <br /> I Live oak.,Rd. I( a reverse for map) CENSUS TRACT 0�v3-2►o_07 <br /> Owner's Name <br /> Phone <br /> Address 131.9 N. Madison Street f <br /> . � CityStockton <br /> Contractor's Name GOEHRING PUMP IRRIGATION` 309031 Phone <br /> INC. License # .r` <br /> TYPE OF WORK (Check): NEW WELL"/7- <br /> ELL DEEP _ - <br /> ' k /� EN /� RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT /? <br /> + Other /% IN ' <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PITY <br /> 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ofWeII Excavation <br /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> V . Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout., r ; } <br /> Other - Other Information <br /> PUMP INSTALLATION: ' Contractor S ' <br /> F a <br /> i <br /> Type of 'Pump Cga an H.P. 75HP_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR: - _/� State-Work.-Done- <br /> ,DESTRUCTION <br /> tate-Work• Done,DESTRUCTION OF WELL: Well Diameter y <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and. regulations of the San Joaquin Local Health District <br /> i and the State ,of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion. of my work on a new we11f; I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is to t e best of my knowledge and belief. <br /> t <br /> ' SIGNED � � TITLESe <br /> } <br /> DRAW PLOT PLAN ON REVERSE SIDE �1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED HY <br /> ADDITIONAL COMMENTS: DATE ,S'_ a <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' DATE�/ -S''7 T ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING-AND 'FINAL INSPECTION. <br /> E H 1426 <br /> 7172 3M 5 <br />