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81-616
EnvironmentalHealth
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ROCKY POINT
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4200/4300 - Liquid Waste/Water Well Permits
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81-616
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Last modified
7/18/2019 2:53:04 AM
Creation date
12/1/2017 7:28:01 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
81-616
STREET_NUMBER
4102
STREET_NAME
ROCKY POINT
City
TRACY
SITE_LOCATION
4102 ROCKY POINT
RECEIVED_DATE
08/12/1981
P_LOCATION
DON COSE & ASSOCIATES
Supplemental fields
FilePath
\MIGRATIONS\R\ROCKY POINT\4102\81-616.PDF
QuestysFileName
81-616
QuestysRecordID
1911465
QuestysRecordType
12
Tags
EHD - Public
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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF�ICE~USE: APPLICATION OL_O-3 3 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is ` <br /> made in compliance with San Joagiii County rdina a Wo.1862 and the rules and regulations of the San Joaquin Local Health District.. <br /> Exact Site Address o "� City/Town <br /> Owner's Name Phone R J 6 —M <br /> Address �� � �_ City .o.C.9�-4� p� I <br /> Contractor's Name `` License#333�47( Business Phone <br /> Contractor's Address � � 8 T (Z,4 Emergency Phone,�' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No x <br /> TYPE OF WORK (CHECK): NE7VWELL❑ _ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q—PUMP REPAIR❑ <br /> REPLACEMENT❑ I1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Proplerty Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ �iBtJSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing h <br /> ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br />' ❑ DISPOSAL l ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t Surfaca Seal Installed By: <br /> PUMP INSTALLATION: Contractor 41 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done y� <br /> PUMP REPAIR: ❑ State Work Done ! <br /> DESTRUCTION OF WELL: I 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. <br /> Home owner 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 eloy 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call ut Inspection prior to grouting and a final inspection. <br /> Signed X Title: 154 Date: <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I 'I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phases II Grout inspection Phe e I inal Inspection <br /> Inspection By �M Date �.- Inspection By Date �/ <br /> Fee Is Due: Cl ANNUALLY �❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January'l &Received By January 31 ❑ July 1 &Received By-July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE - AMOUNCHECKET <br /> FEE <br /> LESS <br /> PRORATION l� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J� <br /> I afI <br /> Received by Date.11f1 Receipt No. — — Permit No. . Is uance❑ e Mailed Delivered I <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ! <br />
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