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i <br /> 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 ,�-- <br /> (Complete In Triplicate) <br /> Application—is— hereby made t0ithe 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 Reg lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14489 N. Jack Tone Rd. - S Kettleman Ln, , 2UNSU'S'TRACT <br /> List place on W side Ja k Tone <br /> Owner's Name BILL MORGAN•r a Phone <br /> Address 2560 8th Avenue A City ..Concord, Ca <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License li 309031 Phone727-5548 <br /> TYPE OF WORK (Check): . NEW' WELL /-7--'-DEEPEN_ ;77 RECONDITION%� DESTRUCTION /_7 <br /> PUMP INSTALLATION /V PUMP REPAIR / / PUMP REPLACEMENT /7 I <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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.,-- _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout v <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Same as above i <br /> Type of Pump Myers submersible H.P. 7� <br /> _ — n <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION <br /> OF WELL: Well Diameter Approximate 'Depth ; <br /> Describe Material and Procedure r <br /> r <br /> a <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 a to the best of my knowledge and belief. <br /> SIGNED TITLE Sec <br /> retary <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTWN <br /> INSPECTION BY DATE INSPECTION BY _� �{ DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 7/72 IM <br /> . f <br />