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78-1038
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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78-1038
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Entry Properties
Last modified
6/3/2019 10:07:54 PM
Creation date
12/3/2017 12:02:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
78-1038
STREET_NUMBER
15922
Direction
W
STREET_NAME
MADRID
STREET_TYPE
CT
City
TRACY
SITE_LOCATION
15922 W MADRID CT
RECEIVED_DATE
7/3/1978
P_LOCATION
J D MOST
Supplemental fields
FilePath
\MIGRATIONS\M\MADRID\15922\78-1038.PDF
QuestysFileName
78-1038
QuestysRecordID
1836589
QuestysRecordType
12
Tags
EHD - Public
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SAN JOAQUIN-LQCAL .HEALTH DISTRICT <br /> -r FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From 'Date Issued <br /> U- t -3 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 <br /> k_oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ,r ----�� <br /> EXACT STREET ADDRESS -2 16 CITY/TOW <br /> Owner' s Name- Phone <br /> IF <br /> Address City <br /> all <br /> Contractor's Name License Phone� 3z <br /> IS CERTIFICATE OF WORKMAN`S COMPEN TIO"i INSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ _DESTRUCTION E ti <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 SPECIFIC TI <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 Instal e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin' Local ' <br /> Health District. Home owner or licensed agent' s_-sigUj,Ure certifies the following: <br /> "I certify that in the performance of t ork for which 's permit is issued, I shall <br /> not employ any person in such manner a to become subject t Wpr ma 's Compensation <br /> laws of C lifornia. " <br /> I WILL CAL R A GROUT INS.PE Q PRIOR TO GROUT A FI I PEC N. <br /> SIGNED TITLE• . DATE <br /> N i <br /> (DRAW PLOT PL 0 V SIDE <br /> FOR DEPART USE ONLY �i <br /> PHASE I <br /> APPLICATION ACCEPTED BY tizaz DATE 7-7 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIOyN BY DAT �f -'j <br />,�1426 RPv_ 12-77 ____ 1 /78 2M <br />
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