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73-375
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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73-375
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Last modified
4/1/2019 10:07:18 PM
Creation date
12/5/2017 5:09:21 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
73-375
PE
4366
STREET_NUMBER
21300
Direction
E
STREET_NAME
ACAMPO
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
21300 E ACAMPO RD ACAMPO
RECEIVED_DATE
7/26/1973
P_LOCATION
DALE STENECK
Supplemental fields
FilePath
\MIGRATIONS\A\ACAMPO\21300\73-375.PDF
QuestysFileName
73-375
QuestysRecordID
1629903
QuestysRecordType
12
Tags
EHD - Public
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N, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 91601 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 L 3 <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 /> OB ADDRESS/LOCATIONi )�: i �% CENSUS TRACT S 4 7 <br /> er's Name;<' 1 J 3 Phone <br /> N <br /> Address <br /> City <br /> Contractor's Name C - �r' o-" License % Phone_ j` <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN /-7 RECONDITION /-7 DESTRUCTION / <br /> PUMP INST TION / / PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE PF WELL CONSTRUCTION SPECIFICATIONS C.y <br /> Industrial Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private Drilled Dia. of Well Casing ; <br /> omestic/public Driven Gauge of Casing ) e-0— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout f J � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 f my knowledge and belief. j <br /> SIGNED <br /> �,� �x t l�r� c - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 7 -2 DATE ,, ' U INSPECTION BY A DATE -' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />
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