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80-1032
EnvironmentalHealth
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ROCKY POINT
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4255
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4200/4300 - Liquid Waste/Water Well Permits
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80-1032
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Last modified
7/1/2019 10:41:51 PM
Creation date
12/1/2017 7:28:42 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-1032
STREET_NUMBER
4255
STREET_NAME
ROCKY POINT
STREET_TYPE
CT
City
TRACY
SITE_LOCATION
4255 ROCKY POINT CT
RECEIVED_DATE
12/08/1980
P_LOCATION
DALE COSE
Supplemental fields
FilePath
\MIGRATIONS\R\ROCKY POINT\4255\80-1032.PDF
QuestysFileName
80-1032
QuestysRecordID
1911536
QuestysRecordType
12
Tags
EHD - Public
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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE.USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> " - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_�OCk-y_PO]Llt C Lot 3 oriesidg Sub pity/Town <br /> Owner's Name Dale COSe Phone A4 , <br /> AddressP.O* Box 32 City nray- O <br /> Contractor's !Name Hennings BT'OS, License#_29087 3_ Business Phone 5)_5-0271 ' f <br /> a <br /> 3525 PelandaleModesto Emergency Phone �� 1 <br /> Contractor's Address d <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> .TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ (" <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 1001 Cesspool/Seepage Pit Other tJu <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �l <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PV ;* <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT . <br /> ❑ DISPOSAL ❑ OTHER Other information SLAB-BY OWNER _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILR ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTI6N OF WELL: Well Diameter Approximate Depth r <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 f <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , <br /> Homeowner or licensed agent's signature certifies the following:1 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 for which this , <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X HENNINGS BROS. BY Dale: 12-1 -80 z <br /> (Draw of Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date /2 -fid <br /> Additional Comments: <br /> se II Grout I spectionase.11l Fin In ction <br /> Inspection B ate /�-/'7- �C> Inspection By -ate 3--5-- '/ <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT ❑ PER SITE 0 EACH ❑January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED r <br /> AMOUNT <br /> FEE <br /> w V-3 <br /> LESS �Y <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER - <br /> e <br /> OTHER <br /> I�2 64 5�5k3 6y6l3 <br /> Received by pate Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYtCES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
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