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74-379
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4200/4300 - Liquid Waste/Water Well Permits
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74-379
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Last modified
4/12/2019 10:06:01 PM
Creation date
12/1/2017 12:01:30 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
74-379
STREET_NUMBER
1400
STREET_NAME
WATERLOO
STREET_TYPE
RD
City
STOCKTON
APN
14115002
SITE_LOCATION
1400 WATERLOO RD
RECEIVED_DATE
7/24/1974
P_LOCATION
TILLIE LEWIS FOODS - PLANT D
Supplemental fields
FilePath
\MIGRATIONS\W\WATERLOO\1400\74-379.PDF
QuestysFileName
74-379
QuestysRecordID
1977309
QuestysRecordType
12
Tags
EHD - Public
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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP,,OFFICE USE: I/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 3� <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 /> 113 a <br /> JOB ADDRESS/LOCATIONS CENSUS TRACT <br /> Owner's Name r `' Phone <br /> Address CityAczt/L� <br /> Contractor's Name �r �� License Phon.C? r <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/-7 RECONDITIONDESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 P C <br /> Other /% - — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ Its <br /> �— <br /> Disposal ' Other - Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , - . • <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP I.REPAIR: /-7 State Work Done <br /> ES-TRUCTION OF WELL: Well, DiameterI� <br /> �(Ir Approximate D pth O � <br /> Describe Material and Procedure <br /> 11-U r. f <br /> I hereby agree to comply with all aws 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. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROU G AND A FI T INSPECTION, r�_ <br /> SIGNED TITLE /"�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y DATE z <br /> ADAITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIJ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / /l_7 <br /> ' E H 1426 Rev. 1-74 <br /> 1-74 2M <br />
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