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QUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 SAN JOAE. Hazelton Ave. , Stockton, Calif. P <br /> Telephone: t209}'''466-6781 `r l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z6 -39,3 V <br /> 7G- G�9l-a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 lit, CENSUS TRACT <br /> Owner's Name - Leonard- Means Phone <br /> Address 648 East Alameda St. <br /> Man fpr-q <br /> Contractor's Name Manteca PlumbingCompany P one <br /> 185808 S23-..2423 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /X-/ DEEPEN / / RECONDITION AL / X <br /> _/ DESTRUCTION / <br /> PUMP INSTALLATION /—/ —PUMP PUMP REPAIR /—/—PUMP PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1. 00I SEWER LINES 60i PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 10Or 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 1211 <br /> X Domestic/private X _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal 50 <br /> Cathodic Protection Rotary Type of Grout en oni to <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor MantecQb ' <br /> Type of Pump k5u0mersi-ble H.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t'1rdC- 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 best of owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND FI <br /> SIGNED TITLE G'dn/Ti�_L/c <br /> DRAW Pt T PLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a <br /> ADDITIONAL COMMENTS: <br /> PHAU ,AI GR UT INSPECTION PHASE I FIN SPECTION <br /> INSPECTION BY DATE 2 6 INSPECTION BY ATE <br /> I I AM- 3/76 2M <br /> E H 1426 Rev. 1-74 <br />