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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � � <br /> Telephone: f209)'466-6781 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76- 639 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 64?-24 <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 6. 48 East Alameda St. CENSUS TRACT <br /> Owner's Name Leonard Means Phone R25�272 <br /> Address 648 East Alameda Et <br /> Contractor's Name Manteca Plumbing COman License ?g08P one Ap3 p4;)3 <br /> 8 J <br /> TYPE OF WORK (Check) : NEW WELL/X7 DEEPEN / / RECONDITION /-7 DESTRUCTION / <br /> PUMPINSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES 60; PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1001 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 /> X_ Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven ,Gauge of Casing - 1 <br /> Irrigation X Gravel Pack Depth of Grout Seal 50 <br /> Cathodic Protection Rotary Type of Grout Bentonite <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Manteca Plurmb_jA <br /> Type of Pumpr buUmersible H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1AICN Approximate Dept* <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 b o nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND I <br /> SIGNED Dy W PL PLAN ON RE ERSETSIDE)n/TiP' LfG„-rhoLE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA I GR UT INSPECTION PHASE IIVFINAI, IXSPECTION <br /> INSPECTION BY DATE 6 INSPECTION BY 10TATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />