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76-262
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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76-262
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Last modified
5/4/2019 10:07:41 PM
Creation date
12/5/2017 7:08:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
76-262
PE
4373
STREET_NUMBER
8082
STREET_NAME
ASH
STREET_TYPE
ST
City
FRENCH CAMP
SITE_LOCATION
8082 ASH ST FRENCH CAMP
RECEIVED_DATE
05/07/1976
P_LOCATION
WORLD ENTERPRIZES
Supplemental fields
FilePath
\MIGRATIONS\A\ASH\8082\76-262.PDF
QuestysFileName
76-262
QuestysRecordID
1647365
QuestysRecordType
12
Tags
EHD - Public
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_ JOAQUIN LOCAL HEALTH DISTRIC* <br /> FO-67OFFICE USE: 160 Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-2-7o' <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 CENSUS TRACT <br /> Owner's Name � /� � Phone <br /> Address ye?C7 City <br /> Contractor's Name � - }rte_ h� � License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION/-7 PUMP REPAIR'/-7—PUMP REPLACEMENT <br /> Other Ll <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 v <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: • /7 State Work Done <br /> PUMP ,REPAIR: 7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNS TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 74 <br /> E H 1426 Rev. 1-74 4/75 2M <br />
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