Laserfiche WebLink
PPLICATION FOR WELL/PUMP PERM' <br /> SAI�.OAOUIN COUNTY PUBLIC HEALTH SEkV CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 7,0 <br /> (209) 4W-3420 AUG 2 6 1997 <br /> 909-REFUMDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED EIw"'i/PRL J\I��Ei�T.� <br /> (Compote In Triplicate) [�/�FpR�(i�T- L, Ht�"ALTP <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUf;AM1i rig 4i3 <br /> JOAQUIN COUNTY DEVELOPMENT TTI/TLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH BON SII SAN <br /> JOB ADDRESS/OR APN# !Ae"'+ G'J � C�,� jfJ.�,� pARCEt.812E/APNI _ <br /> OWNER'S NAME ( L� ' Y'-^r ` �y j <br /> � ADDRESS�QQ bL3�' '� _� PHONE! /`�I�/4` <br /> CONTRACTOR ADDRESS�U� 7 (i�t![L/1 S' sUCIz—�_ <br /> SUB CONTRACTOR <br /> ADDRESS- y� <br /> UC# PHONE/ <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONIRORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> J <br /> (TYPE OF PUMP) <br /> New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> ❑ ��OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# B�­SOIL B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2.'t GIA.OF CONDUCTOR CASINO A <br /> D <br /> DOMESTIC/PRIVATE ❑GRAVEL PACK/812E TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING 0 <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRiyDATION/AG ❑OTHER GROUT SEAL INSTALLED BV {—l' �''1F� GROUT BRAND NAME f <br /> rf5-,YM/ONITORING GROUT SEAL PUMPED: ❑Vs [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONMAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES <br /> 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 <br /> CALIFORNIA NT MUST CA 24 6 IN ADVANCE FOR ALL REQUIRED INSPECTION$AT(2001400-3422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> Signed X. ,. Title S� Date 6—?0-77 <br /> PLOT PLAN(Draw to Scale)Seale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2_OISTU W OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAN81ON OF SEWAGE DISPOSAL SYSTEM$. <br /> 3. DIMENSIONED OUTLINE$AND LOCATION OF ALL EXISTING AND PROPOSED $. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDWO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted BY Qz__� Dote �/ A,. <br /> Grout Impectlon BY onto Pump Inspection By <br /> Data <br /> Destmetlen Impectten By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER R INVOICE <br /> Z 7900/3 Z <br /> v0 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />