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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE US?E:&' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '�J3 <br /> THIS PERMIT EXPIRES 1 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION we e have no road address as yet-located CENSUS TRACT <br /> directly cro from Camarillo Enterprises N. Atkins Rd. <br /> Owner's Name FRANK r ACO - ��"�'� a 0 ..ay Phone <br /> Address P. 0. Box 639 City Lockeford <br /> Contractor's Name GnPhrj ng Pump & Irrigation, Inc. License # 309031 Phone '727-5548 <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPENRECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION /3a PUMP REPAIR /—/PUMP REPLACEMENT /7T 0 <br /> Other /% -,-- <br /> 0 <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 P" �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Othdr Information Lam- <br /> Geophysical Sutface `Seal Installed" Bv: <br /> PUMP INSTALLATION: Contractor Goehring Pump & Irrigation, Inc. <br /> Type of,Pump Mlry_rs submersible H.P. lOHP <br /> PUMP REPLACEMENT: / / State 'Work Done <br />- PUMP -.REPAIR: / / State Work Done <br /> AES•TRUCTION 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 istrric <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 a torthe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FINAL INSPECTION. <br /> SIGNED TITLE <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 II GRO T INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D T$ < �?g• <br /> E H 1426 Rev. 1-74 It 297 <br />