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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE: ' 1601 E.. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ; 117:3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-2jK <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 14049 E . Rettleman Ln. CENSUS TRACT <br /> Owner's Name Goehring Bros. Dairy, c/o Otto Goehring Phone <br /> Address 13623 E. Victor Rd. , City Lodi <br /> Contractor's Name Goehring Pump & Irrigation,^ Inc. _ .License # -309031Phone � 727=5548 <br /> TYPE OF WORK (Check) : NEW WELL/_/ DEEPEN /7 RECONDITION /7 DESTRUCTION /7 r-•- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD µCESSPOOL/SEEPAGE PIT_ OTHER ZC <br /> PROPERTY LINE -» PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �D0 <br /> INTENDED .USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of We11 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 <br /> t Type of Pump bl H.P. 3/4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: ./'/:, .State Work Done _, w <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 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 /> informatrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOio NG D sA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> F09 DEPARY14ENT USE ONLY <br /> -7 <br /> PHASE I <br /> APPLICATION ACCEPTED BY _;ZJ /,A� r S:2DATE O ld 7 <br /> ADDITIONAL COMMENTS: I I <br /> .. <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f DATE Z41 �f <br /> E H 1426 Rev. 1-74 1177 2M <br />