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SU0000467
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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LOWER SACRAMENTO
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23021
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2600 - Land Use Program
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MS-90-117
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SU0000467
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Entry Properties
Last modified
12/13/2019 10:50:00 AM
Creation date
12/13/2019 9:51:43 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0000467
PE
2622
FACILITY_NAME
MS-90-117
STREET_NUMBER
23021
STREET_NAME
LOWER SACRAMENTO
STREET_TYPE
RD
ENTERED_DATE
9/19/2001 12:00:00 AM
SITE_LOCATION
23021 LOWER SACRAMENTO RD
QC Status
Approved
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SJGOV\gmartinez
Tags
EHD - Public
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r Applications Will Be Processed When Submitted Prcm;.wrfy ComVleled.Be Sure To Sign The Aflpllc~. - <br /> FOR OrFICE USE APPLICATION <br /> (For Non-Transterable,Revocable,Suapendable) <br /> FU"hP&\".rr�L <br /> L_— <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALRY <br /> APP'•Ication Is hereby made to the San Joaquin Local Health District fora permit to construct and'or Install Mework herein described.This application is <br /> made In compliance with San Joaquin C�ounty Or mance No 1862 and the rules and�reJy ulaI of the San uin Local Health Distinct. <br /> Exact Site Address City/Town <br /> Owne,'s Nam �,ez ,L ; , t4 _. —_ Phone --- 1 <br /> Address ,�/—/ - City <br /> Contractor's Name�C s L !!�j' 'E icense aY�/ Business Phone GS - ----v <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compens Ion Insur a nn File With SJLHD) Yes No <br /> TYPE OF WORK (CHECK, NEW WELLCDEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST Septic Tank 1,&-, Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other-___ <br /> Property Line _.._. Private Domestic Well Public Domestic Well <br /> INTENDED USE JffE OF WELL <br /> ❑ INDUSTRIAL MKCABLE TOOL Din of Well Excavation <br /> ❑ DOMESTIC'PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` --� <br /> d-<RIGATION ❑ GRAVEL PACK Depth of Grout Seal —. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: --._-_ <br /> PUMP INSTALLATION: Contractor-____ -__ <br /> Type of Pump - - ---- - _.___H P --- ------PUMP REPLACEMENT: ❑ State Wr:,k Done <br /> PUMP REPAIR: ❑ StateWork Done <br /> DESTRUCTION OF WELL: Well Diameter _ _ _ A p proxImate Depth _ <br /> ' Describe Material and Procedure <br /> I herevy certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances.Ptate laws. and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or icensed 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 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 /> perms' s issued I shall employ sersons subject to workman's compensation laws of California" <br /> I will ca 1 a Gro/ut Inspecti for I grouting and a final Ins7cn. L_ nSigned X _. /' ` �C�iC?�f Title: !` Dater%f/41, i-p/ d <br /> w Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,^ <br /> Application Accepted By �� -- - - Date S�3,o-� <br /> Additional Comments - ------.-.---- ----- ------ _ <br /> Phase 11 Grout Inspection Phase III Final 1spei tion f <br /> Inspr•rllon By �1 0,- Date Inspection By Date 16T <br /> F[[Is DUs: <br /> Ll Ly ❑ PER UNIT ❑ PEn SITE ❑ EAC r. ❑ January I a R cr.e9 By Ja carry' J`—❑ Joy I A A•cPwrf by July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING Rf MITTANCE 1 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE � <br /> LESS <br /> Pn ORATION <br /> P US <br /> PENALTY <br /> OTHER <br /> U'rf t' <br /> p„ �,..•.1 ni Oa I. u...rq••r..: P•.. N” n.,a •D.rn Ma.iM 0.4--dAPPLICANT—ArTUPN ALL COPIE7 TO ENVIRONMENTAL Mr ALTH PEAYIT![P'. IS 16011 MAIIL TON AVI PO 00.30M STOCKTON.CA""I <br />
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