FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL)PUMP PERM,' `r►*at!(AN JOAQUIN COUNTY PUBLIC HEALTH SERVhu,., P,O. BOxENVIRONMENTAL HEALTH DIVISION F 388, 304 EAST WEBER AVENUE, STOCKTpN, CA 95201-38g (209) 466.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 111 It lolb'' fin APPLICATION IS HERE BY MADE 70 THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL tH JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER JOAQUIN T COUNTY AND THE STANDARDS OF SAN CONSTRUCT JOAQUIN NWO INSTAL PUBLIC HEA E WORK DESCRIBED.THIS APPLICATION I1 MATE DI COMPLIANCE WITH SAN JOB ADDRESSOR APNN -225 S'a G��✓(1/t� C J LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. OWNER'S NAME V E�(d �Z CITY [ ULn/' / s ADDRESS 7� /PARCEL SIZE/ApN/ CONTRACTOR /f --iaLIJ_IJ�LfI�lY7A_ ,D`,✓I lj�� J"'�'� 'I7/� C� �I7'v7Gr�I J PHONE X�_ SUB CONTRACTOR ADDRESS ?O �O}(�� UCN Q�►' ,_ PRONE I� ADDRESS TYPE OF WELLJPil ❑ NEW WELLU�— PHONE# ❑ REPLACEMENT WELL ❑ MONITORING WELL M ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 13 OTHER RYP— E OF—PUMP)_ 13New PUMP SET FT,New❑Repair H.P. ❑ VAPOR EXTRACTION WELL b ✓ FIRST WATER LEVEL Res ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL X DESTRUCTION: �`GS ❑ SOIL BORING B COLLA. INTENDED UTE TY O ELL ONbTRUCTION bPECIFICATIONb GYM ❑ INDUSTRIAL ❑OPEN BOTTOMA DIA.OF WELL EXCAVATION❑ DIA.OF CONDUCTOR CASINO DOMEBTICIMATE ❑GRAVEL PACK/612E TYPE OF CASINO/STEEL/PVC D DIA.OF WELL CASING 0 ❑ PU@LK:IMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 11 E MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T CANTMUfT 24 URE Date IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120 1N 4 -3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title / G/j / PLOT PLAN(Draw to Basile)Scale 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. BTRb1CT4NOf3,A%*,t i17t 41G COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ; .....?..................... ... .. .. .. .. .. .. .. .............. .. .. .. ...... :.. .:.. ..<.. ..:............: . ; Application Accepted By Grout Impaction By Date Destruction Impaction By /2 I/ 1 Comments: ACCOUNTING ONLY: AIDM PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECE 3 D b Z