My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
83-510
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
T
>
TRETHEWAY
>
22707
>
4200/4300 - Liquid Waste/Water Well Permits
>
83-510
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
8/5/2019 11:46:23 PM
Creation date
12/2/2017 1:54:27 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-510
STREET_NUMBER
22707
Direction
N
STREET_NAME
TRETHEWAY
City
ACAMPO
SITE_LOCATION
22707 N TRETHEWAY
RECEIVED_DATE
05/25/1983
P_LOCATION
RONALD SCHLENKER
Supplemental fields
FilePath
\MIGRATIONS\T\TRETHEWAY\22707\83-510.PDF
QuestysFileName
83-510
QuestysRecordID
1952009
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
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION ' <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WA'T'ER 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 22707 N. Trethewa City/Town AC O <br /> Owner's Name Ronald Schlenker,'- Phone 369-5080 <br /> Address City '= <br /> Contractor's Name Moorman Is Water �SySteMS License#267 696 _ Business Phone 931-321.0 <br /> Contractor's Address 2120 Wil=k Rel - Emergency Phone <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❑ r.1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION [RX PUMP REPAIR <br /> REPLACEMENT❑ <br /> I <br /> DISTANCE TO NEAREST: I Septic Tank Sewer Lines Pit Privy jt <br /> Sewage Disposal Field. Cesspool/Seepage Pit Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DC/ <br /> OMESTIPRIVATE 11 DRILLED Dia, of Well Casing <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL'. i ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor MOOrman 1 s Water Systems <br /> Type of Pump submersible H,P. 5 <br /> PUMP REPLACEMENT: State Work Done re lace existing um with new submersible <br /> PUMP REPAIR: ❑ State Work Done <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, 7 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 certlfies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X ry Title: . Date: s � ' <br /> { (Draw Plot Ian on Reverse Side) <br /> e FOR DEPARTMENT USE ONLY <br /> F PHASE I r <br /> I <br /> Application Accepted y Date <br /> Additional Comment <br /> Phase II Grout Inspection has�fll speclion <br /> inspection B <br /> P Y Date ,-Inspection By 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING- REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - •.Receipt No. - Permit No. IssLkance D to Mailed Delivered " <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 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.