Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERes ' S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> M. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 \, <br /> (209) 468.3420 UX� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TFlpIk4ftl <br /> APPLICATION 18 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 SAP <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-11115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRE88/Ofl APNR /%O / YV'•«��/7•���j/ /�F JC?2'YJ?U—/2) CITU J�(j4, /ZH PARCEL SIZE/APN/1C}-'(�O <br /> OWNER'S NAME LG�o aW.-1 GI/c; ADDRESS /'�- JJ6i^' S(`, PHONEF YL'/' ]t. <br /> CONTRACTOR �/'a't',•.Y P>S. —�/C i'> C-Ob ADDRESS 1701& Ilmwf/JOL/Z-Ak- UCI PHONE/-172'2-02D <br /> 209 <br /> SUBCONTRACTOR ADDRESS T� ✓_ t/ ✓l/(Ji'f2/!L`�s'1 /�bZL ADDRE88.2v�L',+S Lam-/!t u',k"MY 2L Uctr5222 LE PHONE#'YLS Y712 <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL 11y-��f, MONITORING WELL I ❑ OTHER ira / <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR LJ CROBS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL i J <br /> 13New 11Rop.1, H.P. DEPTH PUMP BET PT. FIRST WATER LEVEL O <br /> RVR OF PUMP) Pte( / <br /> 11 / <br /> OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL F yy SOIL BORING X= B <br /> 11 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATIONfOi� " DIA.OF CONDUCTOR CASING D <br /> 11DOMESTIC/PHIVATE ®GRAVEL PACK/SIZE � tlj TYPE OF CASINGRITEELIPVC �Y/� DIA.OF WELL CASING / D <br /> ❑ PUBUCSMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /0 SPECIFICATION B <br /> ❑ IRRIOATION/AG ❑OTHER GROW SEAL INSTALLED BY Spry lw.00 GROUT BRAND NAME E' <br /> PMONITORING / GROUT SEAL PUMPED: JOY. ON. CONCRETE PEDESTAL BY DRILLEN 11Y. ❑N. SI <br /> APPROX.DEPTH K >!� LOCKING CHESTER BOXISTOVE RPE /✓$4 LIO/T S <br /> PROPOSED CONSTRUCTIONIORIWNG METHOD: MUD ROTARY AIR ROTARY AUGER , CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI <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 WMICI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIREI <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O' <br /> CALIFORNIA.' THE APUCANT MUST CALL 24 HOU IN ADV NCE FOR ALL REQUIRED 1NSPECTIONe AT 120014011S/23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blon.e X TIB. / %"✓r�/!e% 5La'l-L/D!/_f D.t. <br /> �� ROT RAN IDrw to Bore)Scali 'to <br /> T. NAMES OF STREETS OR ROADS NEAREST On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTME.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY �i�/'J <br /> Appll..tl.n gcoepteE BY Otto �` ` L Are. <br /> G'. t ImPectlon BY Deb PvmP I.opoctlon By Deb <br /> Dst,.11.n Inepectlon <br /> Comment.: , <br /> ACCOUNTING ONLY: AIDS FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKFMASH "MOVED BY DAT P"IT/SERVICE RE )JUT NUMBER INVOICE <br /> 29oi 7SP� P� 25 >m 02-73-53 <br />