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" •a""�SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,,:Z;USE: ' 1601. E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit`''Ir7o' <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <br /> (Complete--In--Triplicate) <br /> Application is Aereby 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 Joagui <br /> County Ordinance No. <br /> 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION approx. 18950 N. HEX. 99 • j2lant site. CENSUS TRACT <br /> Owner's Name GOEHRING MEAT COMPANY' Phone <br /> Address P. 0 Box 147, City Lodi ' - <br /> ! Contractor's Name Go <br /> . ehrin Pump & Irrigation, Inc. License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check): NEW WELL '/ f DEEPEN -/_/ RECONDITION /_ DESTRUCTION /_7 .°Q <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT f7 <br /> Other <br /> i 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 r <br /> INTENDED USE 'TY1PE.OF_ WELL , +i-p CONSTRUCTION. SPECIFICATIONS <br /> Industrial ` <br /> j Cable Tool 'Dia. of 'Well Excavation -�- <br /> Domestic/ptivate IDrilled Dia. 1of .Well Casing d <br /> Domestic/public jDriven Gauge of Casing <br /> Irrigation ,.. . <br /> g IGravel Pack Depth of Grout. Sea1 <br /> Cathodic Protecfi�on iRotary ,,;I Type-4of 'Grout ! <br /> k Disposal <br /> 'Others �_ ++ r Other' Information <br /> -Geophysical L - ' Surface Seal Installed B <br /> PUMP INSTALLATION: Contractors +#• ; <br /> Type of Pump F H.P. y <br /> PUMP REPLACEMENT: / / State Work Done <br /> -- <br /> a, PUMP :.REPAIR <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material and Procedure t <br /> I hereby agree to comply with all laws and regulations of the .San' Joaquin Local Health biatrict <br /> and the State of California pertaining to or regulating welil ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Aistrict' a� <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> information e a the best of my knowledge and belief.. I-WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FINAL INSPECTION. <br /> SIGNED, TITLE 3 k <br /> (DRAW PLOT PLAN ON REVERSE SID9) <br /> • j <br /> FOR DEVARTMERZ USE ONLY .. <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE �� �C/ d�Z_ Yl-./- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJfINAL .INSPECTION <br /> INSPECTION BY DATE_ INSPECTION BY DATE �� •� <br /> E H 11426 Rev. 1-74 <br /> _ <br />