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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 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 /> k I 6 <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATION j Mi. W/0 'Ra -'Ad 0. <br /> A. Mi . N 0 Walnut CENSUS TRACT <br />` Owner's Name HOLTHOUSE RANCH Grove Rd. <br /> Phone <br /> Address 7497 W. Walnut Grove Rd. <br /> City Lodi <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC . License #3033 Phone <br /> i - 1 727-5548 <br />-T-Y-PE--OF WORK�-(Chesk)-:ANEW;WELI;4!--Wt—,DEEP•IIN./ ECONDI--T-ION-=�_-�7—DRSTRUC-T-ION-/ - <br /> PUMP INSTALLATION a PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other l/ / <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S <br /> f <br /> Type of Pump Johnston H.P. 60 <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: <br /> State Work Done <br />,DESTRUCTION"OFTWELL: Well Diameter �='�--�- _ <br /> 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 i ue to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> 6 (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE c 7) <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY v PHASEIII FINAL INSPECTION <br /> DATE INSPECTION BY / DATE <br /> CALL FOR A GROUT INSPECT.IONPRIOR .TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M R <br />