Laserfiche WebLink
�3 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �1T <br /> (Complete In Triplicate) <br /> Application is 4ereby 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 Sari Joaqutn' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, 24128 N. Pearl "Road CENSUS TRACT <br /> Owner's Name ANTHONY P. FUNKE Phone <br /> Address_ 24128.N. Pearl,Road City ' Acampo <br /> Contractor's Name Goehring Pump & Irrit 3ation,Inc. License # "309O3lPhone '727-554$ <br /> TYPE OF WORK (Check) ; NEW WELL '/—/ DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 <br /> f, PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /7 (�.1 <br /> Other /..g D struc°tion of well 1" <br /> DISTANCE TO NEAREST: SEPTIC TANK �, SWER LINES PIT PRIVY an" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT OTHER <br /> F.PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOM WELL_'! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'Cable Tool Dia, of Well Excavation <br />€ Domestic/private ` i Drilled Dia. of Well Casing <br /> i Domestic/public w•_ D"ri'ven Gauge of Casing <br /> Irrigation '- <br /> kGravel°Pack Depth of Grout Seal <br /> Cathodic Protection Rotary.; j Type of Grout <br /> Disposal .Other � Other Information 1 <br /> Geophysical = } Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Goeh'rifict Pump r <br /> Type-Of__PumPM-ers- u-b-ifersible-- _ _� _ _- H.P. -:3- <br /> PUMP REPLACEMENT: State Work Done; ~� <br /> PUMP -REPAIRt / / State Work Done <br /> DESTRUCTION-OF WELL: Well Diameter gApproximate Depth " .1$6' <br /> Describe Materialand Procedure filled wZ washed cfravel to h'n 01 ; <br /> 3' below grnd, we cut casing & covered with a cement cap. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />' and the State of California pertaining to_. oi� 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 PORT of the well and notify them before putting- the.-well in use. The above <br />, WELL <br /> ue to the best of< my knowledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G D A FINAL INSPECTION. <br /> i SIGNED ,� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION�iiCCEPTED BY- ,a1-�' 'j'[Qe{/ DATE 4; 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />(: INSPECTION BY DATE INSPECTION-BY DAA E 7 <br /> F E�.H 1426 Rev. 1-74 , 11.77 2M <br />