My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
SU0003518
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
O
>
120 (STATE ROUTE 120)
>
17788
>
2600 - Land Use Program
>
PA-0300115
>
SU0003518
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
11/19/2024 4:01:41 PM
Creation date
9/8/2019 12:33:45 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0003518
PE
2690
FACILITY_NAME
PA-0300115
STREET_NUMBER
17788
Direction
E
STREET_NAME
STATE ROUTE 120
City
RIPON
ENTERED_DATE
5/3/2004 12:00:00 AM
SITE_LOCATION
17788 E HWY 120
RECEIVED_DATE
3/25/2003 12:00:00 AM
QC Status
Approved
Scanner
SJGOV\sballwahn
Supplemental fields
FilePath
\MIGRATIONS\O\HWY 120\17788\PA-0300115\SU0003518\EH PERM.PDF
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
35
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
jJOAQUIN LOCAL HEALTH DISTRICT <br /> iii OFFICE USE: 1.60.,. Hazelton Ave. , ,Stockton, Cal <br /> v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W-30 <br /> ----------- <br /> THIS <br /> -------^ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedtAR 3 - 1978 <br /> (Complete In Triplicate) <br /> Plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin <br /> >unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> i <br /> )B ADDRESS/LOCATION CENSUS TRACT i <br /> mer's Name Phone- c- <br /> :dress <br /> City N <br /> �ntractor's Name 2 License Phone-f_ <br /> 'PE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION _ DESTRUCTION/ / UCTION /? <br /> PUMP INSTALLATION /-j---'PUMP REPAIR /—/—PUMP REPLACEMENT /'7 <br /> Other / / <br /> .STANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY °t <br /> SEWAGE DISPO% FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINZ0 fPRIVATE DOMESTIC WELL ~PUBLIC DOMESTIC WEL <br /> W, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �I( Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private `'`� 44 Ig <br /> Drilled Dia. of Well Casing _ '• �' ! <br /> L A/1 <br /> Domestic/public Driven Gauge of Casing _��� k/e4�c�c!%�� <br /> Irrigation Gravel Pack Depth of Grout Seal Uj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information [� <br /> Geophysical Surface Seal Installed_ By: nu)444ZL Q <br /> !MP INSTALLATION: Contractor <br /> Type of Pump H.P. . . <br /> fMP REPLACEMENT: / / ,State Work Done <br /> JNP ".REPAIR: / / State Work Done i <br /> .SjRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> =ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> iformation is true to th } best of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .IOR TO �5�OUTINGA A P CTION <br /> {GNED " TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> -i.ASE I <br /> PPLICATION ACCEPTED BY DATE a _2-1 28 <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTTO PHASE /FIN INSPECTION <br /> VSPECTION BY DATE INSPECTION BY//51 <br /> F. H 1 L M nom.. 1_ -7 1177 9M: <br />
The URL can be used to link to this page
Your browser does not support the video tag.