My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
82-332
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
A
>
ARTHUR
>
22555
>
4200/4300 - Liquid Waste/Water Well Permits
>
82-332
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/28/2019 10:12:34 PM
Creation date
12/5/2017 7:02:42 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-332
STREET_NUMBER
22555
Direction
E
STREET_NAME
ARTHUR
STREET_TYPE
RD
City
ESCALON
APN
22905027
SITE_LOCATION
22555 E ARTHUR RD
RECEIVED_DATE
7/12/1982
P_LOCATION
LAUGERO BUSINESS INTERPRISES
Supplemental fields
FilePath
\MIGRATIONS\A\ARTHUR\22555\82-332.PDF
QuestysFileName
82-332
QuestysRecordID
1647232
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
App MansWill Be Processed Whg�:4bmittedProperly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: JUL 121982 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> HEALTH ❑1S <br /> SAN Jfl �QUIN#R6NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ;5� �r � APTER QUALITY 2 _q -r,$9_27 <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules a d regulations of the San Joaquin Local Hgalth District. <br /> Exact Site Address — /L t3 �,S,J - <br /> �ity/Town i1�0 <br /> Owner's Namehone 3 <br /> U f <br /> /cS �` <br /> Address '� ^ S' City .%:) r <br /> Contractor's Name , o License# a�4? /0 Business Phone_ f�:7 Q� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_A2 14 No r, <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ p,1W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION 1:1PUMP REPAIR❑ <br /> REPLACEMENT 11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump H P <br /> PUMP REPLACEMENT: I$State Work Done -+ <br /> PUMP REPAIR: ❑ State Work bone <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 with San Joaquin County ` <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. N <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this _A <br /> permit is issued, I shall employ persons subject to workman's compensation law of California." fi <br /> I wil I for a Grout I ec' prior to grouting and a final inspect <br /> Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Q� /`� tr e G Date �J '2� <br /> Additional Comments: <br /> PrII Grout Inspection as III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> KILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> m -(54 lX 1,651Y /s-1 6 <br /> Received by Date Receipt No. - Permit No. Issuance Date Mailed Delivered 3 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />
The URL can be used to link to this page
Your browser does not support the video tag.