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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE 'OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S -7� <br /> ' <br /> (Complete In Triplicate) 0 <br /> Application is tereby made to the Sam 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 Kennefcl� Rd.'s - See reverse tor map CENSUS TRACT <br /> Owner's Name MACHADO VINEYARDS Phone <br /> Address P. 0. Bax 754, Lockeford Calif. City ' <br /> Contractor's Name. Goehring Pump & Irrigation, Inc. License # :309031 Phone 722-5-j4f3 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 Nary' <br /> PUMP INSTALLATION PUMP- REPAIR / / PUMP REPLACEMENT /7 _ ! <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 /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool :Dia. of Well Excavation ' <br /> Domestic/private Drilled of Well Casing AL_- <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 Informationi,f <br /> Geophysical ' - Surface seal: 'Installed By <br /> PUMP INSTALLATION: Contractor _ Same aa abQve ,, <br /> Type of Pump Delta turbine H•P- 20 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: µ x . .,/ / State Worker Dorie <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe. Material, and -Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health b istrict <br /> and the State of .California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work ona 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 i true to the best of my knowledge- and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G' NG/,,AND A FINAL INSPECTION. <br /> SIGNED' Z, s TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SIDS l <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I: <br /> APPLICATION ACCEPTED BY �( �CJ --- -- DATEn <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> f77 2M <br /> V U 9L7G n___ 1 -7/. ' <br /> i <br />