FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ED ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl{u in TrOrkat{) APPLICATION IS HEM BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORESSIOR APH/ 13737 S . AIRPORT WAY CITY MANTECA, CA 9 5 3 3 61ARCEL SIZEJAPN/1 98-03-03 OWNER'S NAME (' TIF ('R nnT R �nN� (l�_ADor-*BsC)0-8 RiTRY C'T_ , RTPnN, C'A P+4oNE.209-471 —1 % CONTRACTOR\/ 9W nRTT T TNC' , TNC' ADDRESS PO BOX 51 uc# 720904�oNE# 7073742£ SUB CONTRACTOR As R I 0 VISTA, CA 9 uCi 1 a� PHONE. TYPE OF WELVPVMP; Cl NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I Cl OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL/ J ❑New❑Pe .I' H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ 0 SOIL 80R1NG 4 B ❑DESTRUCTION: C'T OqF BORING WITH NEAT CEMENT GROUT AFTER SAMPLING INTENDED USE TYPE OF WELL CON{TRUC710N SPECIFICATION{ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIRUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO O ❑ PVBL)CIMUNtCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ tRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E ❑ MOMTORINO GROUT SEAL PUMPED: ❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER:Cl Ye. [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DIaLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER GEOPROBE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND MOULATIONS OF THE SAN JOAOIRN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOP"A.- CONTRACTOR'S ERRING OR SUB-CONTRACTtNO SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMrr 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIONAM'{COMPENSATION LAWS OF CAUFOFWIA.' T PRN.IC ANT MU{T C S HO IN ADVANCE FOR ALL REOLARED INSPECTIONS AT(2001440-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. -= Slt,..se x � �.l� rl C L�` na. PLOT PLAN(Dl—to Sa.1el Se.l. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY- 2. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,ORMJO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLnrFB AND LOCATION OF ALL EXISTING ANO PROPOSED i. LOCATION OF WELLS VKTHrN RAOnJS OF ONE HUNDRED FIFTY FT, STRVCTVRERI 8,MCLVDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS• ON THE PROPERTY OR ADJOMRp PFIOPERi'Y. .. .......... ..... ..........- r. rr.... ..r li DEPAP MENT USE ONLY (///]& n� Applfa.tten A.oepted BY D.t. // V I • / MM 6 Grout t—Pe 6—BY D.ta Pt v In.veetlen By Dw. D D�tnrctbn Irwvectbn Y .I. cemment.: ACCOUNTING ONLY: AID# FAC! PE CODES FEE INFO AMOUNT RE WTTED CHECK/!CASH RECEIVED BY DATE ►EFPMTISERVICE REQUEST NUMBER INVOICE c10 �B 1042-