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82-445
Environmental Health - Public
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4200/4300 - Liquid Waste/Water Well Permits
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82-445
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Last modified
7/29/2019 10:10:21 PM
Creation date
12/1/2017 10:42:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-445
STREET_NUMBER
15265
STREET_NAME
VICTORY
City
OAKDALE
SITE_LOCATION
15265 VICTORY
RECEIVED_DATE
08/26/1982
P_LOCATION
JOE DUTRA
Supplemental fields
FilePath
\MIGRATIONS\V\VICTORY\15265\82-445.PDF
QuestysFileName
82-445
QuestysRecordID
1969135
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE: ppncarronswm BeProcessedWhen Submitted Properly Completed. Be o Sign ThI' i n <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) UGIP <br /> ENVIRONMENTAL HEALTH PERMIT �1 'Q , ELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DIMICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Coun y Ordiante No. 1862 and the rules and regulations of the San Joaquin Local He Ith Dlstr1'C . <br /> Exact Site Address j `� \- <br /> City/Town 0-1/-- <br /> Owner's <br /> -}LOwner's Name C _ <br /> Address �� Phone <br /> City K3�7 <br /> Contractor's Name pJt License#�223 /fa Business Phone Y SCJ I } <br /> Contractor's Address �Q._ �v S _ Ci w Inkl4ergency Phone 3 r,-/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNor <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN 11RECONDITION E DESTRUCTION❑ <br /> k WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP ElINSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> 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 ❑ { <br /> DRIVEN Gauge of Casing ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> El DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �. S rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor l'1 cy,, t.-r" \I—.- <br /> Type of Pump S3,,b, H.P. 2 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done { <br /> DESTRUCTION OF WELL: Well Diameter E <br /> Describe Material and Procedure Approximate Depth <br /> C '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 orsub-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 /> IW" for a Grout 16,spection prior to grouting and a final insp <br /> Signed X <br /> Title: .. t �`' Lt <br /> �a Date: � -�✓ 2 <br /> (Draw Plot Plan on Reverse Sid ) <br /> PHASE FOR DEPARTMENT USE ONLY <br /> Application Accepted By 06 1 , <br /> / <br /> Additional Comments: Date ? �_`L� <br /> Phase 11 Grout Inspection ! ha a Ili Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT <br /> 13 PER SITE ❑ EAGH1 <br /> ❑ January 1 &Received By January 31 ❑ Juiy 1 $,Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHEfl <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ssuance aie Mailed - Delivered <br /> . A ., 1601 E.HAZEL'TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
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