FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT �-+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV?tfS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate► APPLICATION IS 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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNQ!p kjjA" �( � CITY /l PARCEL SIZE/APNI OWNER'S NAME rIL a ADDRESS 2[ ,� /—PHONE# CONTRACTOR F I ADDRESS /?,OR 1w UC#G a 2X7 PHON15,5"s-1p y SUB CONTRACTOR ADDRESS UCI ~ PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I (TYPE OF PUMP) New❑Repair H.P. DEPTH PUMP SET FT, La--f0_11. LEVEL O 11OUT-OF-BERVICE WELL 114 GEOPHYSICAL WELL# I901L BORING R 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 201.`N DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELJPVC _ DIA.OF WELL CASING 0 ❑ PUBLIC/MUNICIPAL ❑OMVEN DEPTH OF GROUT SEAL SPECIFICATION_ R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY �-�/ GROUT BRAND NAME E 11 MONITORING /I�� GROUT SEAL PUMPED: [I Yee fp No CONCRETE PEDESTAL SY DRILLER:❑Ym []No 5 APPROX.DEPTH 2-0 , +Ln 15b LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE%8Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION 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 18 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 19 ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APP LICANT MUST CALL 24 IN ADVANCE FOR ALL REQUIRED INSPECTI ONS AT 12091408-S423. COMPLETE DRAWING AT LOWER AREA PRO 0. 4 `� Signed X �it�ty�l�_�, Title D(�t�T—' Date z �f / PLOT PLAN(Draw to Scale)goals 'to 1. NAMED 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 BYSTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, 7L t �2 I DEPARTMENT USE ONLY /�J ( •'�'j(, Application Accepted By Data IP' 241 -1 J Arw Grout impaction By Date Pump tnapoetion By Data Deatnretion Impectlon By Date Comment.: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PEtMITISIERVICE REQUEST NUINBEt INVOICE 50 '85 1:2- 0 2.21 q 6 Pub.Health Serv.-Enviro.173(3/96)