FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

5I j/ e �v r /?'��r1 ire EAPPLICATION FOR WELL►PUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (109) 409.3410 MON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ICompbte in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOW 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 14EALTIJ SERVICES,ENVIRONMENTAL HEALTH DIVISION. Q JOB ADDRESS/OR APN/ ;?V 700 S. ,B,gh�j, �ca CZ Clrt, /racy 511 7 PARCEL SIZE/APN# .2.S.Z\ �O�tYC�/Cc// OWNER'8 NAME__B1l/ PUI�e �P.eai/a (� ADDRESS ��7� Is Q „ ��r� PHONE#(4709) B.AS 4 7�7 CONTRACTOR Gt.,�c•f2�iy� �nr��w� X3'3 X7.3 er-I� ADDRESS-��a �„�i' 1,4 Uae_ SSS/S'7 S PHONE-- ADDRESS ( _ �*' OUR CONTRACTOR ADDRESS UC+1 PHONE I 7;"'/� TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ® OTHER_6jrjZ%L jZ& /j ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I (TYPE OF PUMP) 11 Now ElRePoIr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 11OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL I ❑ SOIL SOnING S 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION- DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA.OF WELL CASINO D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ® MONITORING GROUT SEAL PUMPED: 11V« ❑Ne E CONCRETE PEDESTAL BY DRILLER:❑V« ❑No S APPROX.DEPTH a o r LOCKING CHESTER BOX/BTOVE PIPE S PROPOSED CONSTAUCTION/DRILUNQ METHOD: MUD ROTARY AIR ROTARY AUGER e_ CABLE OTHER - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1416 PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE AP CANT VST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001460-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X i Tille Dete100� PLOT PLAN(Drew to scale)Bode 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. see �4h�. pec/ ft Tire /� 1tTT� .�aGcL..>�rue-,.s rNP-1 ,moi,r ,C w. DEPARTMENT USE ONLY APPllcetlan Accepted By�/� t Data ` (,r ( W Arae Grout Inepecllon By /' ��` (Qnote�a`'T ( pump Inepectlon By Date D«trtwtlon Impeetlon By Date Commenter (`I r\ W 1 ' ►\ l �'i11 {''�L' 1. qw ACCOUNTING ONLY: AID/ FAC,1 PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIIV.EDD,By DATE}�Q PERMIT/SEJR�VICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)