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79-958
EnvironmentalHealth
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JACK TONE
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4200/4300 - Liquid Waste/Water Well Permits
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79-958
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Entry Properties
Last modified
6/30/2019 11:01:58 PM
Creation date
12/2/2017 5:47:13 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
79-958
STREET_NUMBER
24973
Direction
N
STREET_NAME
JACK TONE
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
24973 N JACK TONE RD
RECEIVED_DATE
08/27/1979
P_LOCATION
ROBERT ERICKSON
Supplemental fields
FilePath
\MIGRATIONS\J\JACK TONE\24973\79-958.PDF
QuestysFileName
79-958 (2)
QuestysRecordID
1794240
QuestysRecordType
12
Tags
EHD - Public
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' Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneAppncauon. <br /> _cr:fCE USE: APPLICATION' <br /> (For Non-Transferable, Revocable, Suspendable) _ <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin„Local Health District fore permit to construct and/or install the work herein described.This application is <br /> ' made in compliance with SanJoaquinCounty Ordinance No. 1862 a d e rules and regulations of the San Joaquin Local Health District. 'I <br /> Exact Site Address / 9 7 7"Z City/Town <br /> L/' r <br /> Owner's Name Phone J—( —^ <br /> ° Address ; .�+ City <br /> Contractor's Name mm LJ� _/ License# Business Phone � � <br /> Contractor's Address 1 3 Ga s C Emergency Phone ff e, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNod <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 1:1RECONDITION Elw DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL�` f <br /> REPLACEMENT❑ <br /> a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy + <br /> k <br /> . Sewage Disposal Field Cesspool/Seepage Pit Other . <br /> Property Line Private Domestic Well Public Domestic Well ' "I <br /> INTENDED USE TYPE OF WELL r ,, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation III <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> E ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth-of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout AI <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑_'GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'I <br /> Type of Pump .. �.C�� H.P. r G tr+ <br /> r PUMP REPLACEMENT:" { ❑ State Work Dane <br /> PUMP REPAIR: State Work Done �1 -Q ,I� �c 4— <br /> ► DESTRUCTION OF WELL.- x. Well Diameter Approximate Depth f <br /> ` Describe Material and Procedure <br /> I hereby certify that 1•'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_Healt'h_D.istrict. T_ <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> t t workman's compensation law's of California." <br /> is issued, I shall not employ any person in such manner as to become sublet o p <br /> Contractor's hiring or sub-contracting signature certifies 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 /> I will all for a Grout I spection prior to grout' and a II Ii inspection. <br /> Signed X Title: - - Date: <br /> ' + 1,4agraw Plot Plan on Rever Side) <br /> j { F FOR DEPARTMENT USE ONLY <br /> PHASE <br /> z <br /> Application Accepted By Date <br /> Additional Comments: ` <br /> Phase II Grout Inspection Phase 111 Final Inspection 7 <br /> Inspection By Date Inspection By Dat <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT= ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> 1 REMIT ' <br /> BASE EXPLANATION AMOUNT DOE CHECKEp <br /> BILLING REMITTANCE $ - <br /> DATE OATS REMITTED <br /> AMOUNT <br /> t / y <br /> FEE S i/ <br /> LESS <br /> PRORATION <br /> - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> DN)I <br /> 7 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered off <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 y <br />
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