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75-234
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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75-234
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Entry Properties
Last modified
4/22/2019 10:07:38 PM
Creation date
12/5/2017 2:21:55 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
75-234
STREET_NUMBER
6810
Direction
E
STREET_NAME
FAIRCHILD
City
STOCKTON
SITE_LOCATION
6810 E FAIRCHILD
RECEIVED_DATE
06/10/1975
P_LOCATION
ST & E RR
Supplemental fields
FilePath
\MIGRATIONS\F\FAIRCHILD\6810\75-234.PDF
QuestysRecordID
1761825
Tags
EHD - Public
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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFICE USE: j 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 06-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />! THIS PERMIT EXPIRES T '711° <br /> 1 YEAR FROM a DATE��ISSUED 8• Date ''issued <br /> (Complete,ln Triplicate) <br /> Application is hereby made to the San Joaquin Local District, for `a pea?mit t'o construe <br /> and/or install the work herein described. This application !is made`'in campliance-with San .Toa uiji <br /> County Ordinance No. 1862 and. the Rules d q <br /> ,Rsgulat ons o . t an Joaquin Local Health District'. <br /> C��(d .----•�- -�r�r , Wit , <br /> F JOB ADDRESS/LOCATION 41 '''" <br /> /�� kk CENsuS TRACT `. <br /> Owner°s Name <br /> i <br /> Phone . <br /> Address w ` <br /> City <br /> Contractor's Name <br /> f . <br /> License-. 'j Phone <br /> TYPE OF WORK (Check): <br /> � WUNP ELL ' DEEPEN /? RECONDITION /? EM <br /> DESTRUCTION 17 t <br /> NSTALLATION PUMP REPAIR / /—PUMP REPLACEMENT 17 , <br /> Other _ . . . • �4 <br /> - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> STAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ! <br /> PROPERTYoI.TNE_=`PRIVATE D(}MESTIC WELL P�IBI,IC l}OMESTIC WELL- <br /> IN <br /> TENDED USE �,.,r•TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ <br /> Domestic/private. ' <br /> �'r. Cable 3'001 Dia. of Well Excavation <br /> r Drilled N Dia. of Well Casing •• <br /> Domestic/public Driven Gauge of ,Casing Q <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary - <br /> Type of. Grout C� <br /> Other Information <br /> " Geophysical �w � Surface Seal-Installed S <br /> ��' w... f� <br /> ' <br /> PUMP INSTALLATION: Contractor o, <br /> Type of PumpH.P. � <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP !REPAIR: /,;, State Work Done <br /> ESIRUCTION OF WELL: I - <br /> W�31 Diameter Approximate Depth! <br /> Aescribe Material and Procedure p ----- <br /> I hereby agree to complyij,with all laws and regulations of the San Joaquin Local Health District <br /> and the Stateof California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work new well, I will furnish the San Joaquin Local Health District a• <br /> WELL DRILLERS REPORT of t well and notify them before putting—the.—well in use.. The above <br /> information is true t e bes <br /> PRIOR TO GROUTT INS ECT ION edge and belief. I WILL CALL FOR"A 'GROUT INSPECTION <br /> SIGNED , • _. . <br /> li TITLE <br /> ( PLOT PLAN ON REVERSE SID 1 <br /> 'RASE I a OR DEPARTMENT USE ONLY <br />` 'APPLICATION ACCEPTED BY <br /> IDITIONAL COMMENTS: Ij DATE 4 —/d <br /> PHASE ROUT NSPECTION ��1�11_RAL,�3:RSPECTIO <br /> I:PECTION BY DATE �� INSPECTION B � DATE .- 7 <br /> � H 11+26 Rev. I-74 <br /> 1-7 G 7M <br />
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