FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP IPERMI-1 I SAN JOAQUIN COUNTY PUBLIC HEALTH $ ES ENVIRONMENTAL HEALTH DIVISION .1 P.O, BOX 3W 304 EAST WEBER AVENUE, *OCKfON1 gg CA SMI- (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED (Cowls%in Triplintal / APPLICATION f8 HERE BY MADE 7Q THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALLIITHE WORK DESCRIBED.THIS APPLICATION IS MADE IN MPLTgNCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVI810N, JOSADDRESSIOR APN# Victory Park, 1201 Pershing Avenue Stockton 135-150-01 CITY PARCEL SIZEJAPN# OWNER'S NAME City O Stockton ADDRESS 425 El IIDorado Street PHONE# 937-8829 i CONTRACTOR The Twining Laboratories, Inc. _ ADDRESS PO Box 1472 Fresno uc#C57-50615%oNE# 268-7021 SUBCONTRACTOR .ADDRESS Ca.p 1193716 „,,,._... IJC# PHONE# I TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL la-MONITORING WELL# MW-1 13 11INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR II ❑ VAPOR EXTRACTION WELL ITYPE OF PUMPI 13New IJRepalt H.P. DEPTH PUMP SET FT. 'r FIRST WATER LEVEL p ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# 'E ❑ SOIL BORING g DESTRUCTION: INTENDED USE TYPE Of WELL CONBTRUC7IAN SPECIFICATIONS I .I A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8.5!11 ib DIA.OF CONDUCTOR CASING N/A U ❑ DOMESTIC/PRIVATE I GRAVEL PACKISIZE 2 12 TYPE OF CASING/STEEL/PvcPVC Sc hl 40 DtA.OF WELL CASINO 211 D F ❑ PUBLICAMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 12.5 f tl V SPECIFICATION—y$('.h 40 _ R �0 7 IRRIGATKNlAG ❑OTHER GROUT SEAL INSTALLED BY Gravity fill GROUT BRAND NAME VO 1 r Igv F r IaGI MONITORING GROUT SEAL PUMPED: ❑Yee ]WYo I �� CONCRETE PEDESTAL BY DRILLER:Q Yr ❑Ne S I APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPELIu steel cover S PROPOSED CONSTRUCTIQNIDWLIJNG METHOD: MUD ROTARY AIR ROTARY AUGER I� XX 'I CABLE OTHER I II. � I I HF-tEBY 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$61ONATURE CERTIFIES THE FOLLOW N&-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHfCH F - THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNBATION LAWS OF CALIFORNIA.' 6ONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' T=-ANT MUST CALL 24 HOAR&IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120CL 4011.3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. ?, C ��. 81Sned X Title Project Geologist !l Date 6/10/96 PLOT PLAN(Draw to Seals)Seale 'to II I 1. NAMES OF STRER ROA S NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PRO GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. L66ATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ONITHE PROPERTY OR ADJOINING PROPERTY. .....,... . ..... lI :.. . .... ..... Please.;see...attacbed...sheets.:. Drawings ..2..and :4 ..... .. .. . . h =... ......... ............ ...... . ... ... �. . ...... : t .. II .. . -. Il II I .... <.. . :.. .. i I 13 .. . li r . .. .. ;. .. .. .. DEPARTMENT USE ONLY - ep Ya._ 3 % Appllcetlon Acc ted B � ��Date Area ``A I Grout Impaction By ^ Date �'IPump Inspection By II :F Data Oeatrunflon Inspection By ll 1 /',, ,,�� .�^- '-}te r /� l� CIL) ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE I P91MIT1SGMCE REQUEST NUMBER INVOICE Sot (� `meq lZ� i