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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, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued. �J <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 WeEerse <br /> ulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION rrieOak—Rd-.- for ma CENSUS TRACT 063-2to-07 <br /> Owner's Name AETHURT SMIT . Phone <br /> Address 1319. N. Madison Streetf <br /> City Stockton � <br /> Contractor's Name GOEHRING PUMP &, IRRIGATION} INC. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/—/ RECONDITION /7 DESTRUCTION /'7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �' k <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout, . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S am e a 9Mi <br /> Type of 'Pump —Turbine f Qr IH.P. 75HP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMA'-REPAIR: - 47 State-Work- Done <br />.RESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting the well in use. The above � <br /> information is fo t e best of my knowledge and belief. <br /> SIGNED <br /> TITLE Sec C <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � <br /> APPLICATION ACCEPTED BY DATE v,-- <br /> ADDITIONAL COMMENTS: <br /> PHASE iI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY !: DATE /,X <br /> CALL FOR A GROUT/INSPECTION PRIOR TO GROUTING•AND 'FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />