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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO—P-1 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> iCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :12974 X Hibbard Rd. CENSUS TRACT <br /> Owner's Name GARY RUliNICK Phone <br /> ! Address 12974 Hibbard Rd. City - Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC :_. License 309031Phone 727-5548 <br /> k TYPE.OF:WORK (Check) : NEW WELT: /L /.t"aDEEPEN-'/ /;---RECONDITION /�-/ DESTRUCTIONq77 �_�-- -- <br /> PUMP INSTALLATION :'X/ PUMP REPAIR / J PUMP REPLACEMENT / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ✓ -j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4-CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL f' CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool 'Dia of Well Excavation <br /> f Domestic/private , Drilled ''Dia.'Aiof Well Casing <br /> Domestic/public Driven Gauge of Casing N <br /> Irrigation- Tl- Gravel Pack Depth-af-Grout`Sea3 <br /> Cathodic Protection Rotary 'yT}rpe�of Grout . <br /> Disposal W � Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor Goehring Purnp & Irri atian Inc. <br /> Type of Pump 1HP Myers Submersible H.P. 1 <br /> 'PUMP REPLACEMENT: / / State Work Done <br /> 4 <br /> PUMP .REPAIR: / / State Work Done <br /> rDESTRUGTION OF,WELL:�--*-�Well:Diameter-Y - -- -..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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR TO GROU NG A NA INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> E <br /> PHASE I <br /> : APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4� DATE <br /> 1f172M <br /> E H 1426 Rev. 1--74 <br />