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80-856
EnvironmentalHealth
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ROLERSON
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4200/4300 - Liquid Waste/Water Well Permits
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80-856
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Entry Properties
Last modified
7/11/2019 2:25:11 AM
Creation date
12/1/2017 7:30:28 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-856
STREET_NUMBER
2359
Direction
W
STREET_NAME
ROLERSON
STREET_TYPE
RD
City
STOCKTON
APN
16216008
SITE_LOCATION
2359 W ROLERSON RD
RECEIVED_DATE
10/07/1980
P_LOCATION
ELEANORE MAHAFFER
Supplemental fields
FilePath
\MIGRATIONS\R\ROLERSON\2359\80-856.PDF
QuestysFileName
80-856
QuestysRecordID
1911766
QuestysRecordType
12
Tags
EHD - Public
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Appilcetions Will Be Processed When Submitte, illelL:omple>ellaeaure IQ1 ,1 r ��+rr••�•'•� <br /> FOR OFFICE USE: A cIC�TIQN <br /> (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> W QUALITY ` <br /> (COMPLETE IN TRIPLICATE)-�wj�$q•ti✓ �pG �Q✓�" <br /> Application is hereby made to the San JoaquinL ealthDistrictfo ap E rrrilittoconstructand in II h k s i d.This application is <br /> made in compliance ' h San,, agyjr�Co u ty Ordi ce 1862 and the rules a gu alth Distric <br /> Exact Site Address <br /> G* t9 +�..� Ci awn t <br /> Phone <br /> Owner's Name <br /> Address It <br /> Contractor's Name tic nse# Ic s Phone .�- 4 <br /> Contractor's Address Emergency Phone .1 <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No , <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑/ <br /> WELL CHLORINATION 13 WELL ABANDONMENT El OTHER ❑ PUMP INSTALLATION ;/ PUMP REPAIR❑ <br /> 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 i <br /> INTENDED USE TYPE OF WELL D rf <br /> 11IWUSTRIAL 11 CABLE TOOL Dia. of Well Excavation # <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> I] DOMESTIC/PUBLIC ❑ D EN Gauge of Casing e + <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,} <br /> ❑ DISPOSAL ❑ OTHER Other infor <br /> ❑ GEOPHYSICAL r Sea117,! By: <br /> PUMP INSTALLATION: Contractor fly P <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done . <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter - <br /> Describe Material and Procedure <br /> r <br /> T 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 thework forwhich this permit <br />' is issued, a t employ any perso in such m as to become subject to workman's compensation laws of California." <br /> Contra tor's hiring r sub-contractin ig a re erti' s the following:"I certify that in the performance of the work for which this <br /> perm is issued I ail mploy er n s t t rkman' ation laws of California." r <br /> f I wil call for ou spect' n uting and a nal inspection. <br /> I <br /> Signed X" .Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY y� <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout inspection Phase 111 Final inspection <br /> I3 Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> t DATE rATE REMITTED AMOUNT <br /> s FEE r!f_� s0 s <br /> D �U <br /> LESS V <br /> PRORATION <br /> 0 � <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> a c� <br /> Received by Date Receipt No "Permit No. Dance Date Mailed Delivered <br /> .APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Boit 2009 STOCKTOl CA 95207 <br /> k A, <br />
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