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C-X SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ) 1601 E. Hazelton Ave. , Stockton, Calif. <br /> J 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 d-a0 JJ <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Same as below --See reverse for map CENSUS TRACT <br /> Owner's Name HARRY NAKAMURA Phone <br /> Address 9631 E. Peltier Rd. City Acampo <br /> Contractor's Name GOEHRING PUMP & IRRIGATION, INC . License # 309031 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION J / PUMP REPAIR 1(}{/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia-of Well Excavation (_A) <br /> Domestic/private Drilled Dia."-of Well Casing <br /> Domestic/public Driven Gauge of-Casing <br /> Irrigation Gravel Pack Depth,'of Grout Seal <br /> Other Rotary Type Of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. - }E/ State Work Done Changed from 30HP water lube to oil lube & <br /> added 30' column <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 District <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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '/ � DATE 6- 2u-7 7 <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPEC N <br /> INSPECTION BY DATE INSPECTION BY �, DATE Z- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />