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LN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR:0O -PICE USE: 04-11-4601- E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7% -2-95 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (p/ <br /> (Complete In Triplicate) 007- 090-7-0 <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> acrd/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 /> J? 6 5E <br /> B ADDRESS/LOCATION C}ff Liberty Rd. ; see map on reverse CENSUS TRACT <br /> Owner's Name BORGES DAIRY Phone <br /> Address'. 10090 IV E. Liberty Rd. City Galt <br /> Contractor's Name Goehring Pump & Irrigation, Inc. License # 309031 Phone 727=5548 <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT /-7 Qy <br /> Other /% -'-' � <br /> -77- <br /> 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dpm_estic/private Drilled Dia. of Well Casing <br /> TT <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Ca1.thodic Protection Rotary Type. of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f' <br /> Type of Pump ' H.F... <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP .REPAIR: State Work Done Add 20' to 25HP Delta <br /> DESTRUCTION 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 istrT <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 ue to- the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION f <br /> PRIOR TO G A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE s <br /> a <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL COMMENTS.- <br /> ii <br /> - " <br /> PHASE 11.GUT INSPECTION PHASE III/FINAL INSPEC <br /> INSPECTION BY DATE INSPECTION BY DA <br /> EH 2426 Rev. 1-74 i <br />