FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERM", SA,..,OAOUIN COUNTY PUBLIC HEALTH SLICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (COSI APPLICATION IS HERE BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTPRUtCT1ANDF/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,FHAF;TR 8.1 115,.3 AND STANDARDS SAN JOAOUIN COUNTY PUBLIC HEALTH SERCES,ENVIRONMENTAL HEALTH DIVISION. A lrr VI JOB ADDRESS%oR APNI_ r�7,� q•7 l O^-S2. OWNER'S NAMCITY_ i-0 fel CA PARCEL SIZE/APN* E � M L_VD i ADDRESS Z7-4:4 IJCroJ9&ez&Y Gtt�t_G PHONE N CONTRACTOR c 393y• Cfj.c,.grsioGE_ rzc.q� Sr..vT'F._ ZYo ADDRESS,g!j , p ,r t+4 uCrr Syl�l 676 GS 4� rr II PHONE* SUBCONTRACTOR E't/U�A2� (12iL.a_Iy PO - /Lr ADDRESS v✓ls-rA L� �¢57 Cs7 71ba79 '7U7 374 4160i UC4 PHONE M TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ 11 OTHER INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL R VPE OF PUMP) O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* El SOIL BORING B DESTRUCTION: �/I 'T V LN"�I Z 1.1 P%-AUSI r,+ �'L�,A„t..1'T C LL 00T uPPve- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION1 I wJ('..j DIA.OF CONDUCTOR CASING A ❑ DOMESTIC/PRIVATE 11(;RAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC SC.A 4,0 L %,r DIA.OF WELL CASINO !i- 111 C„/ D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S<<( 4,c, Pv L R ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY 2C,., 1 4_ GROUT BRAND NAME E MONNORINO l WAi�t/L- t1GTi//!,('.-t�C,-J GROUT SEAL PUMPED: Vrr ❑Ne CONCRETEEDESTAL BV DRILLER:❑Yea P ❑Ne S APPROX.DEPTH -44 F^7 LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIVAILLING METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER — I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THEE APPJPU RT UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2001480-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sloned X Tltle -r s7 Date uC•2 9� PLOT PLAN(Draw to Scdei Sod@ 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURE8,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, ... ...i... .. .'....... .i.. .... ........ AP...;.. .. . .......... ... ' I ....:..... ... :. i _:....: ...i ...: '............i. ...._.. ......... ........... _. ..:....' . fy/Iy,�1 r DEPARTMENT USE ONLY q ADpilc@tlon Accepted Sy 1. c Dote. -7 I I Ara ` Grout Inapecllen By Date Pt p Inopeetlon By Dote Opatnrctlen Impectl@n By Y `--t bete Cemmentr._ V V� / �� •1'�Q�1 2 /.` �1 l / ACCOUNTING ONLY: AID/ FAC*' PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE D 1 Pub.Health Serv.-Enviro.173(1/97)