My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
82-256
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
H
>
HAM
>
11046
>
4200/4300 - Liquid Waste/Water Well Permits
>
82-256
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/27/2019 10:11:42 PM
Creation date
12/2/2017 2:01:47 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-256
STREET_NUMBER
11046
Direction
N
STREET_NAME
HAM
STREET_TYPE
LN
City
LODI
SITE_LOCATION
11046 N HAM LN
RECEIVED_DATE
06/09/1982
P_LOCATION
RAY HINTZ
Supplemental fields
FilePath
\MIGRATIONS\H\HAM\11046\82-256.PDF
QuestysFileName
82-256
QuestysRecordID
1739731
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
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 /> /I^441e, <br /> 1'e-'e-e( <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 Districtfora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordi nce No.1862 and the rules and regulations of the San Joaq LoC F�ealth District. <br /> Exact Site Address ��Q �V 1' City/Towna +r <br /> Owner's Name + Phone <br /> Address Affs ity <br /> Contractor's Nam License# �Busines's Phone 146)� ^ 70� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit /SJLHD? Yes 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 Cesspool/Seepage Pit l Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> k11 <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �l DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ <br /> DOMESTIC/PUBLIC UBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst led By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pumps H.P. <br /> PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> e 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 Joaquint_ocal Health District. <br /> Homeowner 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 certifies the following:"I certify that in the performance of the work forwhichthis <br /> permit is issued, I shall employ:persons subject to workman's compensation laws of California."'— <br /> 1 wit call for a Grout Inspectlen prio t6 gro�utlg and 1AI <br /> final inspection. j <br /> r I <br /> Signed X t ''*+ F _� tle: Date: � <br /> (Draw PloWian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �1� Date A <br /> Additional Comments: <br /> Phase II Grout Inspection _ 21h se III f=inal Inspection <br /> Inspection ByDate Inspection BYi [date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 .'1❑cJJuly 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES/ y <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ; <br /> OTHERS - <br /> Received by Date Receipt No. Permit No. - Issuance Date Mailed - Delivered <br /> { 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661 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.
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).