FIELD DOCUMENTS FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT — SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIccS ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 448 N. SAN JOAQUIN ST., STOCKTON, CA 98201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTT1EJR/9- 111115...3�ANO THE STANDARDS OF SAN JOAQUIN COUNNTTYY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION�y JOB ADDRESS/OR AAPNN## /16 gil �kr�+, L�7 {/(/'7�y ,e, �v CITY S/ C,J/tx7ro- �� /�� !/� `PARCEL SIZE/APN# k ' C� OWNER'S NAMEE!T�rfY. � �L�1^4� " 1 '� - ADDRESS ��/ MI6 W� t (��j/,T�.4r2_ b7d)L �W�p r PHONE #_ �p�N4j/a , CONTRACTOR(J'L'V//r/'��/e j�t�n ADDRESS ` �3 � • A4*Ch4 � Y/i&x PHONE # qF• 0U SUBCONTRACTOR 71�i / ///�l �/ L� 'ti] SP�c b2 y / /� � 7 ADORES n�E_��T UC#54ZV-y1�J PHONE #TSI��/�iSZ TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL # ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ New 11Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O ITVPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING S ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS �� A 13 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION25 S DIA. OF CONDUCTOR CASING N / T D ❑ DOMESTIC/PRIVATE 016FIAVEL PACK/SIZE TYPE OF CASING/STEEUPVCf / C/ DIA. OF WELL CASING 2w Zr D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEALL5�1 SPECIFICATION n R ;r❑ II}RIGATION/AG ❑ OTHER GROUT SEAL INSTALLED By GROUT BRAND NAME ap-7V�10FF J MONITORING GROUT SEAL PUMPED: ❑ Ym ❑ No CONCRETEPEDESTALBYDRILLER: ❑ Yw ❑ No S APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DNLUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH S---AN JOAQUIN COUNTY ORDINANCES, S:ATE 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 WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN THE PERF RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNI HE�PUCAI UST CALL 34 URB IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209) 4�68�3 M. COMPLETE DRAWING AT LOWER AREA PROVIDED. So Title. / �� /7/I�/�/ti— Date L PLOT PLAN (Draw to Scale) Scale to 1 . NAMES OF STREETS OR ROADS NEAREST TO 08 BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR 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. IF I l .. .. . A � DEPARTMENT USE ONLY Application Accepted By / " � Date . . . I NI Area Grout Impaction By Date Pump Inspection By Date Dntruction Inspection By Date Comms 2 ACCOUNTING ONLY: AID# EAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE