Laserfiche WebLink
� APPLICATION FOR INELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SER& <br /> ENVIRONMENTAL HEALTH DIVISION 3�3 <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201386 <br /> (209) 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SA <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,,CHAPTER 8-1115..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN/ C_/7L(!^fTJ /[/ C�J%V 16 F',-1e-17/ CITY PARCEL SIZE/APN/��•,J <br /> OWNER'S N >PO , ADDRESS 12, liarSB PHONE / zar <br /> y- 6/E•F <br /> �• �n / <br /> 2701'e- /Md Kr L..p, Oj yo <br /> CONTRACTOR T.•�u�r,E �C-.L'/� [-O . ADDRESS _S' / f/qr CGT RIC/ PHONE#'/7Z -202' <br /> SUBCONTRACTOR t�,��—C'�i?y,•v1 Xj✓/A,2'i917 - /�1/C ADOREBe_2S Gel �.{��55''a.�wi Ate. l <br /> 1p J C�O+f P. C"G LIC/ .J 1.221 J? PHONEY 587/. <br /> TYPE OF WELURIMP: ❑ NEW WELL ❑ REPLACEMENT WELL „qI MONTONNO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑Nw 13 Re air H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C <br /> RYPE OF POMPI l <br /> ❑ OUT-0F-SERVICE WELL ❑ OEORIY6ICAL WELL/ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑r�i11 OPEN BOTTOM DIA.OF WELL EXCAVATION /0 '2 D DIA.OF CONDUCTOR CASING /Z D <br /> 2 <br /> ❑ DOMESTMMRIVATE 9 GRAVEL PACK/SME !� TYPE OF CASING/STEEUPVC e DA.OF WELL CASING �/ D <br /> ❑ RIBI/C/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> RR❑� IRIBOATON/AG ❑OTHER GROUT SEAL INSTALLEDKATBTY �j P�></'(//N�I GROUT BRAND NAME E <br /> 10 MONITORNG r'�-'7 65-,q. <br /> 1 GROUT SEAL ROMPED: 16R Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y� [11% 5 <br /> /APPROX.DEPTH L / — [.�S, . LOCKING CHESTER BOX/STOVE RPE ✓( U CX S <br /> WOMBED CONSTRUCTIONIORIWNG METHOD: MUD ROTARY X AIR ROTARY AUGER CABIE OTHER <br /> -- <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS ARROCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANI <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S MONATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH <br /> THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERNREI <br /> 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 D <br /> CALIFORNIA.- PIG AMVCANT UST CALL HOUR!IN ADVANCE FOR ALL REQUIRED INSMY DW AT 13M1 COMPLETE COMPUTE DRAWING AT LOWER AREA PROVIDED. , <br /> 81'r x / Tm. D.I. <br /> PLOT RAN 113,.,e S .)S.M./'te . 4T 4 \ <br /> 1. NAMES OF STREETS OR ROADS NEA TO OR BOUNDING THE PROPERTY. .. 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 OUTUNF.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 WAMS. ON THE POPERTY OR ADJOINING PROPERTY. <br /> t <br /> r / <br /> .. .... ..... <br /> I <br /> 1 . <br /> _. .: ._.. <br /> DEPMTMENT USE ONLY <br /> ApplleNbn Accepted BY /� MI. <br /> GretX ImpecUon By Dne Pump Iropectlen By D.te <br /> De.nucllen Itipsctbn BY D.I. <br /> ACCOUNTING ONLY' AID( FACT <br /> PE CODEC FEE INFO AMOUNT REMITTED CHECK/MASH RECDV BY DATf FEIVAIT/B9RVICER NlJRB61 I INVOI <br /> 2�0 1600 9 az S 5,2¢D0 Z35S <br />