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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ! <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &/a_-7 <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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 13808 E. Brandt Rd. CENSUS TRACT <br /> Owner's,Name Spiro Anagnos Phone <br /> Address 23457 N. Dustin Rd. City ' Acampo <br /> 0 <br /> Contractor's Name Goehr_inq Pump & Irrigation, Inc. License # 309031. Phone 727-5548 <br /> 1 J � 'a.� t <br /> TYPE OF-WORK"("Check) —NEW WjzLi / % `DEkPEN` 77 `RECONDITION f_f 4 E T06T_1ONT7 s <br /> PUMP INSTALLATION )E PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <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 /> Domestic/private Drilled Dia, of Well Casing <br /> _ I <br /> Domestic/public Driven Gauge�of„Casing,__,.�— -----_ <br />" "�""Trrxgation �­'..,..� Gravel Pack Depth of Grout Seal , q• <br /> Cathodic Protection Rotary Type of Grout T�. ' <br /> Djsposal Other ""- Other'Information ¢ <br /> Geophysical Su-r-face Seal Instal-led.-By-.-- a <br /> PUMP INSTALLATION: Contractor Go6hring Pum <br /> Type of Pump 15HP Johnson Turbine H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> — x <br /> PUMP -REPAIR: / J State Work Done <br /> .r- .�,.—u. :�.s�--�,._..�_ •..rte—x-. .. —. -'•- <br /> DESTRUCTION OF WELL: Well Diameter ~_ Approximate Depth <br /> Describe Material and ,.Procedure <br /> F <br /> I hereby agree to comply with all laws -and �re'gulations of the San" Joaquin Local Health District , <br /> and the State of California pertainingrtto ori-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 wellin use. The above <br /> information 's e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 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 '/2 <br /> ADDITIONAL COMMENTS:. <br /> PHASE 'II GROUTk-INSPECTION PHASE III FINAL INSPECTION 7� <br /> INSPECTION 'BY DATE " ' INSPECTION BY DATE S -Z <br /> E H 1426 Rev. 1-74 _ <br /> 1/77 2M ,� <br />