FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

• APPLICATION FOk-KELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER S ENVIRONMENTAL HEALTH DIVISION P,O- BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201988 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripFcabl AP CATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMFVANCE WITH S/ JOAQUIN COUNTY DEVELOMEE T TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIIONMEMK HEALTH DIVISION. JOBADDREBBroR//AIJ'N4 RrVf4/1k3-//020-/2 // CITY ,Q7?actlOA,/ 1/ )/ P/A/ACIFLL mMAPNE OWNER'S NAME/A'Ir/>Yi✓rYi �IfEY.I/C� 6A10. AODRE66lPV/WI9v��W/l.�VIJ IV1RLR/ALA/IOC 45 /, ./" RONE/ 445-8712- SUB ! CONTRACTG0.�Ai^TQ///yJ X>0 P.44T7fY✓ ADDRESS 2365 AIJG+ /EA1I.11, C71LC/D.V LIOS.572268 C67 PHONE 9445-B7/Z SUB CONTRACTOR `�( ADDRESS UCS PHONE S TYPE OF WELL/RIMP. ❑ NEW WELL ❑ MI CEMENT WELL. Y1( MONITORING WELL S MW"SD,I$ E 19 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR , ❑ VAPOR EXTRACTION WELL I ❑Nwv❑IMP.Ir H.P. DEPTH POMP SET—FT. FIRST WATER LEVEL RYPE OF PUMP( ❑ OTR-0FSERVOE WELL ❑ OEOPHYSYCK WELLS BOIL BORING ❑DESTRUCTION: INTENDED USE TYPE Of WELL CONSTRUCTION ZKCIRCATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION II DIA.OF CONDUCTOR CASINO -- ❑ OOMESTIC/PPoVATE 0GRAVELPACK/1ARE42IZ � TYPE Of CA61NGATEEIANt SCHEDULE 40 PVC, DIA.OF WELL CASING 41•.cN ❑ FUBLIC/MUNICIPK ❑DRIVEN DEPTH OF GROUT SEK SFE ATTR AR FI t•W_s-S SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY CO—'M -r GROUT BRAND NAME I MONITORING I GROUT SEK POMPED: ❑Yr ❑Ne CONCIIETF PEOESTK BY dlillFR:❑Y. ❑Ne APPROX.DFRTH 25 A—O 8S LOCKING CHESTER SOX/STOVE RPE PROPOSED CONSTAUCTIONANSWNO METHOD: MUD ROTARY X AIR ROTARY AUGER X CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APRICATON AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES,STATE LAWS,AND RULES AI REGULATIONS OF THE SAN JOAOUW COUNTY. HOME OWNER OR LICENSED AOENT'9 SONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PFI60RMANCE OF THE WORK FOR WMH THIS PEPJAIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB{ONTRACTING SIONATURE CERTIR THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMITIS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP"SATION LAWS' CAUPORNIA.' THE APPLICANT MUST CALL 24 OW IN ADVANCE FOR ALL MGUI =INSRECTIONA AT 129-1 4418 2". COMPLETE GRAMM AT LOWER AREA A VIDED. /p Bpn.e X �- � In TIM �P/� d D... �- MOT RAN Uk.. 1.Ba WI I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PIOPERTY. 4. LOCATION OF HOUSE SEWAGE dSPOSK SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. GIMENBIONED OUTLINES AND LOCATION OF ALL EXISTING AND R POSED S. LOCATION OF WELLS WLTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING FROPERTY. /✓1 rAP} Cho �� . No wCAow.Tme�t.f a... T USE ONLY DM. 7 Avvliutbn AuaP..d BY Grout UnPectlen By D... ps.u-tbn IrNp.ctlon BY wW l O r l cemmRR.: "7ZLGtJ 56 s>.�- r. w-->f ACCOUNTING ONLY: NDS FACS PE CODES FEE INFO AMOUNT REMITTED CHEc"MASH RECEIVED BY DAT PETWOT/SERVN:a IIEGUEST NUMBER INVOICE z