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80-502
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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LOWER SACRAMENTO
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23801
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4200/4300 - Liquid Waste/Water Well Permits
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80-502
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Last modified
7/6/2019 11:05:47 PM
Creation date
12/2/2017 11:28:12 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-502
STREET_NUMBER
23801
STREET_NAME
LOWER SACRAMENTO
STREET_TYPE
RD
SITE_LOCATION
23801 LOWER SACRAMENTO RD
RECEIVED_DATE
6/10/1980
P_LOCATION
JAHANT RANCH
Supplemental fields
FilePath
\MIGRATIONS\L\LOWER SACRAMENTO\23801\80-502.PDF
QuestysFileName
80-502 (2)
QuestysRecordID
1834432
QuestysRecordType
12
Tags
EHD - Public
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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 1 \\ <br /> (For Non-Transferable, Revocable,Suspen lj <br /> ELL <br /> ENVIRONMENTAL HEALTH PER I <br /> ZrcA.t l S 4-rtrVI tF <br /> W C"r% WL T-_1,0Leir� WATER d <br /> (COMPLETE IN TRIPLICATE) �"� QUALITY ��� � � 19SOx <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and./or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules an regulations ofgAJqanJi�l it Ih9 tchi 1Weai L.District. <br /> Exact Site Address /1�4 e ��. ��� City/TovIq 'rlDISTR!CT <br /> Phone 003 C�—0/ <br /> Owner's Name �-- <br /> Address r O- , yam! City a <br /> Contractor's Name License#/re 23�3 Business Phone <br /> Contractor's Address 00JI D t• Emergency Phone G^5P(_ -Z-t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <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 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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T ) <br /> ype of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractor °p <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: 2State Work Done <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. <br /> Homeowner or licensed 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I PY call r a Grout nspec' n prior to grouti g and.a final insp tion. <br /> Signed X Title: Date: / d <br /> Q <br /> (Draw o Ian on Reverse ide) <br /> /<= <br /> RTMENT USE ONLY <br /> PHASE f <br /> Application Accepted 8y. `"'` Date 4 c1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ill Final Inspection <br /> Inspection ByPll� _ Date InspectionBy Date <br /> Fee Is Due: ❑ ANNUALLY ElPER UNIT ;KPER SITE ElEACH ❑ January 1 &Re <br /> d By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE __ $ REMIT <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE /�•i� r�� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
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