My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
80-234
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
S
>
SINCLAIR
>
150
>
4200/4300 - Liquid Waste/Water Well Permits
>
80-234
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/2/2019 10:52:03 PM
Creation date
12/1/2017 9:22:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-234
STREET_NUMBER
150
Direction
N
STREET_NAME
SINCLAIR
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
150 N SINCLAIR AVE
RECEIVED_DATE
04/07/1980
P_LOCATION
MARLEY COOLING TOWER COMPANY
Supplemental fields
FilePath
\MIGRATIONS\S\SINCLAIR\150\80-234.PDF
QuestysFileName
80-234
QuestysRecordID
1925023
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
T Applicons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 6FF16E`USE: APPLICATION <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> t Exact Site Address 150 North Sinclair _ City/Town Stockton <br /> r Owner's Name The Marley,C.00ling Tower Company Phone 465-351 C>> <br /> Address <fi 0` North SinclaA `5 City Stockton <br /> Contractor's Name Clark Wei & Equipment License#371560 Business Phone 462-5597 Address 2024 E• Charter Way Emergency Phone NA �1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORT( (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank + ?_5 Sewer Lines +75' Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line+10 Private Domestic Well +100' Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10 5&n <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �t6 5/8" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing , �7 12 Steel Pipe <br /> 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �, - O <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout Be -=---- ev <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Clark pry <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> t PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ra. <br /> ` Describe Material and Procedure <br /> #{l 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r 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 i ill all for a Grout Inspection prior to grouting and a final <br /> I� inspection. <br /> Title: <br /> Dr. Date:Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I C1 -7 <br /> Application Accepted By _ Date <br /> Additional Comments: <br /> has I Grout IIns�ection 7` Pha II Final Inspection <br /> Inspection By 11 -Ao Date rl V Inspection By �(c � y <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive ByTanua?y ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �j AMOUNT <br /> 4 FEE j 3 "f'( 43 <br /> [ LESS E <br /> II PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> OS31S <br /> Received by Date Receipt No. Permit No. - Issua ce D to Mailed Delivered <br /> I - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
The URL can be used to link to this page
Your browser does not support the video tag.