My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
76-585
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
M
>
MARIPOSA
>
3506
>
4200/4300 - Liquid Waste/Water Well Permits
>
76-585
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
5/9/2019 10:10:47 PM
Creation date
12/3/2017 1:18:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
76-585
STREET_NUMBER
3506
STREET_NAME
MARIPOSA
STREET_TYPE
RD
SITE_LOCATION
3506 MARIPOSA RD
P_LOCATION
LEER CONSTUCTION
Supplemental fields
FilePath
\MIGRATIONS\M\MARIPOSA\3506\76-585.PDF
QuestysFileName
76-585
QuestysRecordID
1844278
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
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEi FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7,1-- EgZp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z <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 CENSUS TRACT <br /> Ownerrs Name Phone <br /> Address City <br /> Contractor`s Na License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/? RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR /-7—PUMP REPLACEMENT f T <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 Q <br /> Domestic/private Drilled Dia. of Well Casing a� <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: / / State Work Done <br /> PUMP :REPAIR: /� State Work Done _ <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 UTI AN .A F N INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7•i6 .7�. <br /> ADDITIONAL COMMENTS: <br /> °•— <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 142. Rev. 1-74 -- - 1-74 2M <br /> _, <br />
The URL can be used to link to this page
Your browser does not support the video tag.