Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> ,AN JOADUIN COUNTY PUBLIC HEALTH SERVIL.,, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST:WEBER AVENUE,STOCKTON,CA 55201388 <br /> (209)499.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TTipliatt) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> ��1PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DM8ION. <br /> JOB ADDR—SMR API/_131�t5N-41 .lr� `.J•}f� f�CITY `fes PARCEL 8IZE/APN/.41 a,/137" <br /> jo0-12 <br /> OWNER'S NAME CW—M,-) PYDAJOFS(pmpph• ADDRESS P•O-Bmoc 6C1�}. r Q.--�a_PHONE1 (510) Bit 2.-SGR5 <br /> SOCONTRACTOR PdTGiG Eny.Or. }al (�ip� ?NG ADDRESS.II315 .S�nfiLG-C�old1GYTJCLt5e� 3-Da,a LICIQt+ (o2.bD PHONE/1R16)65B-I3$D <br /> SUBCONTRACTOR �(� �IL< V—k, �,CA 95714L <br /> iG t'�F-!1 LN'il� E.nytwvtw ta[ ADDRESS P.O.BoX 7131 UC/ ('72617 PHONE#P10852-7556 <br /> Oo. cl 497'li <br /> TYPE OF WEUJPUMP: ❑NEW WELL 13REPLACEMENT WELL 13MONITORING WELL/ ❑OTHER <br /> 13INSTALLATION 13WELL SYSTEM REPAIR E3 CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL <br /> RYPE OF PUMP) <br /> 13N—E3R..w, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O i <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ V(tO1L BORI a g <br /> ❑DESTRUCTION: <br /> INTENDED USE YPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/81ZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D <br /> ❑PUBLIC)/AUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑^IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ICS.MONITORING GROUT BEAL PUMPED:❑Y« ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yr [IN. 5 <br /> APPROX.DEPTH W LOCKING CHESTER BOX/STOVE HPE ,S <br /> (-io Il 6"— <br /> P110POSED CONSTRucTIO WNO METHOD: MUD ROTARY Am ROTARY AUR .f CABLE OTHER <br /> I HE%EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,I WALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR KGSLOHTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED,1 WALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.'THE MINT CALL 24/OURS IN ADVANCE FOR ALL RSGUIPIM INSPECTIONS AT 120014"4423.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slmrd K lV/!(JM/" i nn.- .eke D.t. 4+123/97 <br /> / <br /> ROT PLAN ID—I.SW.1 Soal. 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GAL SY <br /> NG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSASTEMI. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALYS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> -... <br /> .. <br /> i. <br /> a. <br /> h .- <br /> C" <br /> ... <br /> Vi!t <br /> I: _ . .. . <br /> DEPARTMENT USE ONLY <br /> Appl"llon A—pt.d By 1 D.t. <br /> Gout Inpwtlon BY \ D.t. P—P I—Pwtlon BY D.t. <br /> Dw—tbn Urpwtlon BY D.t. <br /> C.- <br /> -ACCOUNTING ONLY: AID/ FAC! <br /> PE CODES FEE INFO AMOUNT REFITTED CHECK//CASH RECEIVED NY DATE P'EINeT/SEIWICE REQUEST NUMBER INVOICE <br /> 3501 2,L4 4,(I. ) n2 <br />