My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
78-1150
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
V
>
VICTOR
>
13611
>
4200/4300 - Liquid Waste/Water Well Permits
>
78-1150
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
6/4/2019 10:18:15 PM
Creation date
12/1/2017 10:39:56 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
78-1150
STREET_NUMBER
13611
Direction
E
STREET_NAME
VICTOR
STREET_TYPE
RD
City
LOCKEFORD
SITE_LOCATION
13611 E LOCKEFORD RD
RECEIVED_DATE
07/25/1978
P_LOCATION
ROGER MAILLOUX
Supplemental fields
FilePath
\MIGRATIONS\V\VICTOR\13611\78-1150.PDF
QuestysFileName
78-1150
QuestysRecordID
1968938
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
W <br /> SAN JOAQUIN ,LO,CAL HEALTH DISTRICT <br /> EQRFFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit No. <br /> 7 -11 <br /> Telephone: ' (209) 466-6781 " <br /> APPLICAT-ION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> 'This Permit Ex ires 1 Year From Date Issued---- . � <br /> Complete In Triplicate <br /> Application is hereby made to the Sari 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 <br /> Joaquin County Ordinance:No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ` +�/� �'; 10 C— <br /> D b - CITY/TOWN Lock-�PvtzQ ^_ <br /> Owner's Name Q Phone ,57-- 24?dS <br /> AddrCs.s c _ Ci ty .51r ek,rpl/,l <br /> Contractor' s NameLicense# -70-7, Phone 41 Z�' <br /> t <br /> IS CERTIFICATE OF WORKMAN'S M11PENSATION INSURANCE ON FILE WITH SJLHD? YES .d0 <br /> TYPE OF WORK Check) : NEW WELLP6 DEEPEN L7 RECONDITION [ DESTRUCTION M <br /> WELL CH ORINATION 0 WELL ABANDONMENT 0 OTHER n c� <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK ��t-SEWER LINES /,51 +IT PRIVY JV&- 51 <br /> SEWAGE DISPOSAL FIELD/07f-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 Excavations <br /> Domestic/private W D,r:i,11-ed Dia. of Well Casing <br /> Domestic/public--z Dr_.i ven $: .4 Gauge of_Casing <br /> Irrigation Gravel Pack i �a< Depth of Grout SealR _ <br /> Cathodic Protection Rotary ` Type of Grout C C- <br /> Dis <br /> Disposal ! .. - L_ -- <br /> P Other-- - �� � �� Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUNDlr INSTALLATION: Contractor <br /> Type- of Pump. ; H.P. <br /> PUMP. RERLAICEMENT: � w — � <br /> [] State.,Work�Done-----� <br /> PUMP REPAIR: ` Q State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat-6rial and Procedure <br /> I her certify that I have prepared this application and that the w <br /> PP e rk o w311 be done in -4ccordance <br /> pith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> gealth 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 P y an y person in such manner as to become subject to Workman's Compensation <br /> laws of alif ni <br /> C WILL CAL OR GR T I S ECTION PRIOR TO GROUTING AN AL INSPECTION. <br /> iiGNED TITLE DATE: <br /> DR W PLOT�PLN ON REVIERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HASE I . <br /> APPLICATION ACCEPTED BY ,� ATE <br /> kDDITIONAL COMMENTS : q 7 <br /> PHASE II GROUT INSP CTIONPHASE III I L INSPECTION <br /> NSPECTION BY ��� � DATE S -2 -^may, INSPECTION BYDATE <br />:H 1426._. Rev. 12-7.7 �� _ _ 1 /7A 2W <br />
The URL can be used to link to this page
Your browser does not support the video tag.