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80-121
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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MILTON
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19650
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4200/4300 - Liquid Waste/Water Well Permits
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80-121
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Last modified
7/1/2019 10:54:25 PM
Creation date
12/3/2017 2:48:55 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-121
STREET_NUMBER
19650
Direction
E
STREET_NAME
MILTON
STREET_TYPE
RD
City
LINDEN
SITE_LOCATION
19650 E MILTON RD
RECEIVED_DATE
3/3/1980
P_LOCATION
LAWRENCE FILIPELLI
Supplemental fields
FilePath
\MIGRATIONS\M\MILTON\19650\80-121.PDF
QuestysFileName
80-121 (2)
QuestysRecordID
1854039
QuestysRecordType
12
Tags
EHD - Public
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I -» ApplicationsWill BeProcessed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> [b /6 (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 186 and the rules an regulations of the San Joaquin ocal Me Ith District. <br /> Exact Site Address y 4+ City/Town <br /> Owner's NamePhone �2 <br /> Address City <br /> Contractor's Name +7-j� License# >6 Business Phone 76 U <br /> Contractor's Address D w Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes�)t-2 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ �. <br /> REPLACEMENT❑ J <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 /> Od DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Q` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> O <br /> ❑ GEOPHYSICAL , Surface Seal Inst ed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump b H.P. / <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP>I : State Work Done fo&? SeX in 01,ge <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 /> Home owner 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 will all for a Grout InsEpytioliI ri ing and a final inspection. <br /> Signed X Title: Date: <br /> (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI r <br /> Application Accepted By Date �d <br /> c <br /> Additional Comments: <br /> Phase II Grout Inspectionase Inspection <br /> Inspection By Date _ nspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t & eceived By July 3t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DDE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5 <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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