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82-159
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4200/4300 - Liquid Waste/Water Well Permits
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82-159
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Last modified
7/26/2019 10:07:45 PM
Creation date
12/2/2017 10:11:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-159
STREET_NAME
LOCKEFORD
SITE_LOCATION
LOCKEFORD
RECEIVED_DATE
05/03/1982
P_LOCATION
US DEPT OF THE INTERIOR
Supplemental fields
FilePath
\MIGRATIONS\L\LOCKEFORD\0\82-159.PDF
QuestysFileName
82-159
QuestysRecordID
1825440
QuestysRecordType
12
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EHD - Public
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r Applicalione Will Be Processed When Submitted properly Completed. Be Sure To Sign The Application. <br /> _41:t h#offICE ugt! _ 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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliancelith San Joaqut +Co my Ordinance No. 186Z and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address7 <br /> City/Town N <br /> Owner's Name Phone <br /> Address City E .0 <br /> Contractor's Name ��License# Business Phone <br /> r Contractor's Address S 00 lr.? 6-C (; --- mm Emergency Phone # <br /> 15 Certificate of Wgrkman's Compensation ins n o on FIiO With SJLHD7 Yes No <br /> TYPE OF WORE( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 'WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR El -� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 'Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing __ w <br /> ❑ DOMESTIC/PUBLIC ❑ 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 I Surface Seal Installed By: <br /> ! PUMP INSTALLATION: Contractor <br /> ° Type of Pump H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ) ❑ State Work Done <br /> DESTRUCTION OF WELL: L rWell Diameter_—_ _ ApproX. at Depth <br /> Descri a Mat rial and Procedure �Q, <br /> C <br /> I hereby certify that I have prepared this app lcati n and that t{1 work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rues and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r� <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." C <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this `r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: ���' <br /> V Date: <br /> (Draw Plot Plan on Reverse Side) <br /> d FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> a i <br /> Application Accepted By d l ' Q —"" Date ` <br /> Additional Comments:_C�n_ <br /> Ph a II Grout Ins ectl Phase III f=inal Inspection <br /> I Inspection By <br /> In <br /> By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PEA SITE ❑ EACH ❑ January 1 &Received By Janunry 31 ❑ July 1 &neceived By July 31 <br /> BILLING REMITTANCE ; RL <br /> BASE EXPLANATION AMOUNT DUE f CHDATE RATE REMITTED A <br /> EE <br /> L <br /> LESS <br /> PRORATION <br /> PLARS <br /> PLNALIY � M <br /> ' <br /> OTHER t <br /> k OTHER i <br /> rf 1 <br /> Received 6y Dal Receipt No. Per '47Issuance Date Mailed Delivered <br /> APPLICkiT—*RETURN ALL COPICS TO: ENVIHo#MhH7AL HEALTH PEnM1T/SEnV%CCS 1601 E HAZCLTON AVE._P.O.oo.annu crnrrrrnu re—1— <br />
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