FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

} APPLICATION FOR WELLIPUMP PERMIT jffi OSAN JOAQUIN COUNTY PUBLIC HEALTH SERflM ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469-3420 MON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE By MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMIEE (NT TITLE,CHAPTER)19-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONM/[1NTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 1247 LtMu s9 4eP— )�./ CNYs4zx-' 1 /�+�) 1(,-3 -"5-'n LTi/Ly PARCEL 812E/APN# /.j-[ p !� /p�/� '� OWNER'S NAME 67&0 1,0t)P..FIlri1 ! i1/ ADDRESS E�J`i5, c�fb st /NC' ?>l.L1 �7_�`� PHONE f,L22-3'7/ COMPACTOR !moi (LIQ 1- V1c ADDRESS.141,< ~/ryl. '.^� ICr 11 LIC# 72 r,je,4 PHONE• 74-Z,-/S SUB CONTRACTOR ADDRESS "I' ` l / LIC/ PHONE i TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REMCEMENT WELL MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J (TYPE OF PUMP( ❑New❑ReP.lr H.P. DEPTH PUMP MT—FT. FIRST WATER LEVEL 2/1 O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A ❑ INDUSTRIAL T11 r�1 OPEN BOTTOM DIA.OF WELL EXCAVATION_ (C� OTA.OF CONDUCTOR CASING J O ❑ DOMESTIC/PRIVATE Id GRAVEL PACK/BRE 21,- TYPE OF CASINGMTEELIPVC DIA.OF WELL CASING ? �� O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SU I'. FITC SPECIFICATION �3ew 4":1 q 1EJ11 IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED K yBBV LC-11 `Vd1 ic✓ GROUT BRAND NAME E 0 MONITORING GROUT SEAL PJMPED: 93 V. ❑No CONCRETE PEDESTAL BV DRILLER:❑V. IVN. S APPROX.DEPTH .�� / LOCKING CHESTER BOX/STOVE PPE__ s PROPOSED CONSTRUCTION/DI&WNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUSCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING- .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- IE PUC MUST C 24 OURS IN ADVANCE FOR ALL REQUIRED I PECTIONS AT ROeI 4&&J422. COMPETE DRAWING AT LOWER AREA PBOVIDEO. 61prd X 2 Tltle / C-,1�t /II Dete PLOT E(Drew to Scale)Sole�� 'to S 1LUA7 1. NAMES OF ST ETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUR( E OF E PROPERTY',GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENS ED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. N N 5ca1e.% ( W �) �Z ) ® o' laD• BLOCK 39© I IF 1 F /6/. 25 I APPROXNAiE LOCATION j< �,, .� IlwBpplKlHlt rTGGH:ID O 1145 W. Mortar Way I < ® O 6 I•, . M0.1-4 )� R A .Alt ;a„eT,L. l l ) 1245 W. Ctle~Way vt/ NO. k _ I _T DEPMTMENT USE ONLY ''�� 1/�} Apppue0on Accepted By L Det- 2'o `+/ Ar. Grow Impoctlon BY Del. Pump Inspwtlon By Det. D.tructlon ImPootlon BY Det. Commenb: \ ' ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY D11TTEQ� PERMIT/&FIiVICE REQUESTTNNUNBE R INVOICE O 1 V