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76-588
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4200/4300 - Liquid Waste/Water Well Permits
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76-588
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Last modified
5/9/2019 10:04:35 PM
Creation date
12/2/2017 3:50:04 PM
Metadata
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Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
76-588
STREET_NUMBER
5233
STREET_NAME
HICKORY
City
STOCKTON
SITE_LOCATION
5233 HICKORY
RECEIVED_DATE
07/19/1976
P_LOCATION
JOHN FAHEY
Supplemental fields
FilePath
\MIGRATIONS\H\HICKORY\5233\76-588.PDF
QuestysFileName
76-588
QuestysRecordID
1751563
QuestysRecordType
12
Tags
EHD - Public
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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,.CF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> y APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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 Regula/tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �'� c �/C a CENSUS TRACT <br /> Owner's Name o ej Phone ' <br /> Address City <br /> -71 <br /> Contractor's Name �� License #49 Phone <br /> kTYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION /? DESTRUCTION f7 • � <br /> PUMP INSTALLATION j / PUMP REPAIR -7 PUMP REPLACEMENT f7 <br /> Other <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 <br /> : .-PUMP INSTALLATION: Contractor C3 L <br /> Type of Pump -� U H.P. <br /> r PUMP REPLACEMENT: . / j State Work,iDone <br /> PUMP .REPAIR: <br /> & 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 /> rafter 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 FORA GROUT INSPECTION <br /> . PRIOR TO GR .0 G AND A FINAL INSPECTI0 <br /> SIGNED &t _ TLE <br /> DRAW rL2X PLAN ON REV SE SIDE <br /> Fff DEPARTMENT USE ONLY <br /> PHASE I �- <br /> APPLICATION' ACCEPTED BY DATE ' <br /> -�� <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROAT INSPECTION -.PHASE III FINAL INSPECTION <br /> INSPECTION BY _DATE ti ZINSPECTION BY v DATE --- ? �� <br /> f ��,; <br /> - _ h/752M <br /> E H 1426 Rev. 1-74 \ - r _- - ,M <br />
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