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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF. E ' SE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 N <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7K-4�J v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is > ereby 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 Distrtct. <br /> r <br /> JOB ADDRESS/LOCATION Liberty Rd. - See reverse for map CENSUS TRACT_ <br /> (we do not have a road address or it. ) - <br /> Owner's <br /> .Owner's Name BORGES DAIRY Phone <br /> Address _ ifMa 10090 E.. Liberty Rd. City ' Galt <br /> Contractor's Name Goehrin Pump '& Irrigation, Iiac. License # 309031 Phone '727=5548 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION j -PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f 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 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 <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Installed BX: <br /> l <br /> PUMP INSTALLATION: Contractor Same a�k�ove <br /> Type of Pump e u I .P. - <br /> PUMP REPLACEMENT: / / State Work Done <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 Health biitrict <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 Distrigt a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> informatio i ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO CG AND A FINAL INSPECTION. <br /> SIGNED ( TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (�� -- _ <br /> APPLICATION ACCEPTED BY DATE v <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 14:26 Rev. 1-74 1/7.7 ' 2H <br />