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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 ?� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-0 -7 7 <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 24712 N. Graham Road CENSUS TRACT <br /> Owner's Name Leonard Mitchel Phone <br /> Address 24712 N. Graham Road City Acampo <br /> Contractor's Name Goehri-na Pump & _Irrigation, Inc. License #309031 Phone ' 727-5548 <br /> T <br /> TYPE OF WORK (Check) : NEW WELL /—T DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ PUMP REPLACEMENT CL} <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �J <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 /> Domestic/public Driven Gauge of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary FType of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ r <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: X/ State Work Done replaced 1 ZHP sub. with new 1 2HP Myer s sub <br /> ,.PUMP .REPAIR: State Work Done <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 bistrict <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 ORT of the we Yl a-nd-notify,thembefore-putting the .welt in use. ' The above <br /> informati ue to the best of,my _Jrnowledge,and:-belief. I WILL CALL .FOR A-GROUT INSPECTION <br /> PRIOR TO G D A FINAL INSPECTION. ' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /J <br /> APPLICATION ACCEPTED BY �J DATE ? <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1/77 2H <br />