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75-237
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4200/4300 - Liquid Waste/Water Well Permits
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75-237
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Last modified
4/22/2019 10:06:22 PM
Creation date
12/5/2017 7:31:28 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
75-237
PE
4369
STREET_NAME
AUSTIN
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
AUSTIN RD NW CORNER AUSTIN/ARCH
RECEIVED_DATE
06/16/1975
P_LOCATION
WEIERSHAUSER ESTATE
Supplemental fields
FilePath
\MIGRATIONS\A\AUSTIN\0\75-237.PDF
QuestysFileName
75-237 (2)
QuestysRecordID
1651339
QuestysRecordType
12
Tags
EHD - Public
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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB ©FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ZLZI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5--.23,741 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4—.a- T.�" <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 � � �,�/WC ST �v�N�r� .�j 'J/ Al�C/j CENSUS TRACT <br /> Owner's Name W F1,E 175 fl A VS F l? EL/ ) Lf Phone <br /> Address l�3. I)y6 %/)V 211 1 <br /> City S fGCjrTgW <br /> Contractor's Name C//I (,f/�"L� F1901IOMlNj CG License # G� PhoneS/�,3 77 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/-7 RECONDITION & DESTRUCTION <br /> PUMP INSTALLATION -7 PUMP REPAIR /-7 PUMP REPLACEMENT' /7Other / 7 <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP ,.REPAIR: L7 State Work Done <br /> aS.IRUCTION 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 UTIPG AND ,A F.JNAL IN PECTION. --�— <br /> SIGNED TITLE �� � r✓I �' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I --� <br /> APPLICATION ACCEPTED BY v DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DAT "!` 3INSPECTION BY DATE - 7 <br /> Z <br /> EH 1426 Rev. 1-74 1-74 2M <br />
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