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80-76
Environmental Health - Public
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EHD Program Facility Records by Street Name
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VAN ALLEN
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16348
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4200/4300 - Liquid Waste/Water Well Permits
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80-76
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Last modified
7/9/2019 10:52:26 PM
Creation date
12/1/2017 10:19:40 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-76
STREET_NUMBER
16348
Direction
S
STREET_NAME
VAN ALLEN
STREET_TYPE
RD
City
ESCALON
SITE_LOCATION
16348 S VAN ALLEN RD
RECEIVED_DATE
2/1/80
P_LOCATION
JOHN OVERDEVEST
Supplemental fields
FilePath
\MIGRATIONS\V\VAN ALLEN\16348\80-76.PDF
QuestysFileName
80-76
QuestysRecordID
1966580
QuestysRecordType
12
Tags
EHD - Public
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Applications Will Be Processed When Submitted Properly Completed. u f"64'l46AIpplrtiti <br /> tW <br /> FOR r FICE USE: APPLICATION <br /> s (For Non-Transferable, Revocable, Suspe } 1 1980 <br /> FEBI <br /> y ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> WATER QUALITY SAN 10,,,r IN oCAL <br /> (COMPLETE IN TRIPLICATE) Q STRICT <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or instHFAakk'h rem described.This application is <br /> r <br /> made in compliance with//San Joaquin County Ordinance No. 1862 and t e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /(C(C�3¢� s� ppVAt4 I1ZZ,4/V �+ City/Town <br /> ®sG�i�j`� <br /> Owner's Name ��11 D� U25� / Phone f � �i �I <br /> Address SAn,e— City— 46SeAl <br /> Contractor's Name SU <br /> 77-o kJ 719/i License#0!?OJQ Business Phone 's 49 <br /> Contractor's Address e7qQnA Emergency Phone s,4A?, � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes AIIA2 <br /> " No <br /> TYPE OF WORK (CHECK: NEW WELL 11DEEPEN 11RECONDITION❑ / DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP IN TALLATION ❑ PUMPffPAIRX <br /> REPLACEMENT❑ lAj �t^ '�� � S� �En '�/ CItdNCe�L. <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 /> 99 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 Type of Grout 6f <br /> ❑ DISPOSAL ❑ OTHER Other Information W <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done 3- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 w!Dlffhll for Grout I cti rior to grouting and a final inspec ' <br /> Signed X Title: _ —e 224 <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By "� " 6,6 Date <br /> Additional Comments: o- <br /> Phase II Grout Inspection Phase ill Final Inspection <br /> Inspection By Date Inspection By Date �-27 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER A <br /> OTHER <br /> M <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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