FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH OIYlSlON I P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCI(TON, CA 95201.388 - 1209) 468.3420 3 , NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED (Complete in Triplicate) : Application is here by made to the sen 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, Chapter.9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. ` Job Address/or APN# I L1)9 (_ �4 ,c„ Tf Y U-)C � City ��C C lc �-z,� parcel Size/APN# �C X { L I- I Owner's Name � r tG ., -� S< Address �'I U s �. ti IG C : -- S r r c el• uT Phone # )[ -y Z J _Jr 7C, Contractor Vr:,lc.<r, Y�r r r�`I 2L.$C-c,G,f r%T_ Address tl: _;i u% Ig 5 7. _Ic h,, Lie# 'r-,)LI Ll Phone #tJ( 3 71L F Sub Contractor) 1 e i i 1 4 s ' ` Address ?•0 X ' I "` 6.72 r_ 1 7 r I '� 6 Y �L'�c# Phone #�f Lc'S'a , 5 TYPE OF_ YELL/PUMP: p NEW WELL ❑ REPLACEMENT WELL 11 AONITORING WELL # _.p OTHER [j DESTRUCTION 11 OUT-OF-SERVICE WELL [j GEOPHYSICAL WELL # SOIL BORING 0 INSTALLATION (I WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL # F (TYPE OF PUMP) New [I Repair H.A. DEPTH PUMP SET FT. FIRST WATER LEVEL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • p r � I p INDUSTRIAL [1 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA.DIA. OF CONDUCTOR CASING ; 11 DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING p [I PUBLIC/MUNICIPAL [] DRIVEN "t ''' '' DEPTH OF GROUT SEAL SPECIFICATION- 11 IRRIGATION/AG' OTHER GROUT SEAL INSTALLED BY h� C 1 t I! Lli illuyGROUT BRAND NAME �_c +-< ,•lU '• f ' 1 MONITORINGr 1 GROUT SEAL PUMPED: [I Yes �jNo', CONCRETE PEDESTAL BY DRILLER: [3 Yes p} No APPROX.DEPTH V !� �}LOCKING CHESTER BOX/STOVE PIPE Iv A PROPOSED CONSTRUCTIONIDAILLING METLF�0: MUD ROTARY AIR ROTARY AUGERJ CABLE^ OTHER_ N 3 I hereby certify that I have prepared this application and that the work will beldone in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. Home owner orlilicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I 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 foy which t_hi permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT MUST CALL 24 OUR N N I _0R ALL EOIIIRED INSPECTIONS AT(208)488.3423. Caiplet:e drawing at Lower area provided. } Signed Title U. ? Date 6'1; PLOT PLAN (Draw to Scale) Scale " to '1. Names of streets or roads nearest to or bounding the property. - 4. ' Location of house sewage disposal system or 2- Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal, systems. 3. Dimensioned outlines and location of al[ existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, , the propeety or adjoining property. f and walks. jJ X ELI 6, t SAINJ A !N0 -f SE IC S � I i WkARTMENT USE ONLY I, Application Accepted By Date y ( Aces W IF i 1 Grout Inspection By Date Pump Inspection By. Date I) Destruction Inspection By Date Comments: F ! ACCOUNTING 4HEY: AID# FAC# 1 f I PE CODES FEE INFO AMOUNT REMITTED CHECK11CASH RECEIVED BY DATE { PERMITISERVICE REOUEST NUMBER INVOICE