My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
78-1346
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
E
>
EMERSON
>
4016
>
4200/4300 - Liquid Waste/Water Well Permits
>
78-1346
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
6/6/2019 10:20:01 PM
Creation date
12/5/2017 1:12:35 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
78-1346
STREET_NUMBER
4016
STREET_NAME
EMERSON
SITE_LOCATION
4016 EMERSON
RECEIVED_DATE
09/06/1978
P_LOCATION
JAMES HENKE
Supplemental fields
FilePath
\MIGRATIONS\E\EMERSON\4016\78-1346.PDF
QuestysFileName
78-1346
QuestysRecordID
1732173
QuestysRecordType
12
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: I1601 E. Hazelton Ave, Sto <br /> ckton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. >O_a4l6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/L <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.- 1:862 and the Ru and Regulations of the San.Joaquin.Local Health District., <br /> JOB ADDRESS/ <br /> AT <br /> CENSUS TRACT <br /> .Owner's Name7 <br /> Phone. <br /> Address . City " <br /> Contractor's Name License #/y ,(,,4Pfione 7 .,% <br /> TYPE Ole WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION Fi <br /> PUMP INS.TALLATION '/ / PUMP REPAIR/PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST`.. SEPTIC TANK SEWER LINES PIT PRIVY P <br /> SEWAGE' DIS 5AL 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 f <br /> g Gravel Pack Depth of Grout Sea3. � <br /> Cathodic Protection _1, Ratary. Type of Grout <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 '.REPAIR: <br /> .State Work Done <br /> QESgTRUCTION OF. WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllaws and regulations of the San Joaquin Local Health District <br /> and the State of Californi:a: pertaining to or regulating well •'construction:.. Within FIFTEEN DAYS <br /> after completion of my.: work on4a 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 GROUTIN AND A• FINAL IN PECT.ION. <br /> SIGNS TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE _ T' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP- PLICATION ACCEPTED BY: DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 141 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DljT _ <br /> E H 1426 . 1_0 .�_ <br />
The URL can be used to link to this page
Your browser does not support the video tag.