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-ti <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _IlAu P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_?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 instalr 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/LO CATION 8541 E. Orchard Rd. - in the yard CENSUS TRACT <br /> Owner's Name HAROLD KOENIG Phone <br /> i Address 8541 E. Orchard Rd. <br /> City , Acampo, <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC. License # 309031 Phone 727-5548 <br /> . . i <br /> TYPE_OF-'WORK—(Cluck "NEWWELL^ /_7DEEPEN /_/_RE C 0--N-D I-TI ON /_% DESTRUCTION /-7 v <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 /> — <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 D pth bf 'Grout Seal �' <br /> Cathodic Protection Rotary Typ,& :of-Grout., :,.� �,��,;,� i> �� <br /> Disposal r Other Other Information ` <br /> Geophysical Surface Se 1 -—stalle.dtl <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump- —H.P. <br /> _ y <br /> PUMP REPLACEMENT: / StateF Work Done replaced existina PUMP with2HP .Myers_ submersi- <br /> _ ble - <br />,PUMP ,.REPAIR: / / State Work Done <br /> IDES:TRUCTION OF WELL: Well Diarne ez Approxima-te=Depth <br /> Descrlbe� Material and Procedure <br />. I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land 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 true to the best. offmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRPIWMG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> L t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 1PHASE I <br />-APPLICATION ACCEPTED BY __ t _ „ , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> rINSPECTION BY DATE INSPECTION BY DATE _3v -7 <br /> E H 1426 Rev. 1-74 1 f 27 2�l <br />