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78-1197
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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78-1197
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Entry Properties
Last modified
6/5/2019 10:23:04 PM
Creation date
12/1/2017 2:06:49 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
78-1197
STREET_NUMBER
9251
Direction
S
STREET_NAME
WOLFE
STREET_TYPE
RD
City
FRENCH CAMP
SITE_LOCATION
9251 S WOLFE RD
RECEIVED_DATE
08/01/1978
P_LOCATION
RAY MULLER
Supplemental fields
FilePath
\MIGRATIONS\W\WOLFE\9251\78-1197.PDF
QuestysFileName
78-1197
QuestysRecordID
1990148
QuestysRecordType
12
Tags
EHD - Public
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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FQS-OFFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No._7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued —/-78" <br /> This Permit- Expires 1 Year ,From 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 f <br /> Joaquin ;County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS `,s1: 05qlCITY/TOWN j <br /> Owner's Name Phone <br /> Address 01._V City -r, <br /> Contractor's NameC2,,2License# d), Phone67,5-17 <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENS Tn ItdSURA?ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M A DEEPEN ❑ RECONDITION ❑ DESTRUCTION[:] j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTI� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v <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 1/40 <br /> s <br /> Irrigation Gravel Pack Depth of Grout Seal 66-0 <br /> } <br /> Cathodic Protection =Rbtary Type of Grout o E1'f� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 7 <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 certify that I 'have prepared this application andthat the work will be done in accordance; <br /> with San JoaquinfCounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District, Home owner or licensed agent' s signature certifies the following:- <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> 1 WILL C FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I• FOR DEPARTMENT USE ONLY <br /> APPLICATION,.,ACCEPTED BY . DATE -7(f <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� / DATE , ,, INSPECTION BY �l9. DATE <br />
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