FIELD DOCUMENTS FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WIELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE'S ENVIRONMENTAL HEALTH DIVISION � R I G t �� L P,O. BOX 388,=EAST WEBER AVENUE, ST MON, CA 95201388 (209) 460.3420 LiOq•REFUP]DABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED (Compote In TrfpRoete) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRI .THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH RVICEB,ENVIRONMENTAL HEALTH DIVISION. �I JOB ADDRESSOR APN#d- CIT/ PARCEL SIZE/APNI OWNER'S NAME n ADb 68 °U �q�/� =t-4— STY' CQ VL II. y� V/ W7LICs PHONE 05ZS- \7TJ��DCONTRACTO P-1 r �-t ' A Rve CONTRACTOR V.ri7tA0 pec ADD11E68Z iplev�[_�AAd,r -LK;f a-1']�- PNONE I.90-mans b TYPE OF WELLIPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL# ❑ OTHER t ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I •/ RYPE OF PUMP) ElNew ElRepair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL G ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ,PSL_SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / w A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION v^Y/ DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: [I Yes •�/� [IN. CONCRETE PEDESTAL BY DRILLER:❑V« ❑Ne S APPROX.DEPTH_ !�0_7� � LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DR ILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_ � I"May 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORM FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-0 COMPENSATION LAWS OF CALIFORNIA.' H>:APPLICANT MUST UA10 IN ADVANCE FOR ALL REEG��UCRED INSPW NO AT 1 R 4CO-l422• COMPLETE DRAWING AT LOWER AREA PROVIDED. Q Slpned �l�Qr h/L.Tltl cv-rlt�_ PLOT PLAN(Draw to Seale)Scala •to 1. 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. Y. 03fMVWMEO OUfUNF.O AND LOCATION OF ALL EXISTING AND PROPOCED G. LOCATION OF WELLO WITHIN RADRIO OF ONE HUNDICD FIFTY FT. STRUCTUMO,INCLUDING COVERED ARIAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, DEPARTMENT USE ONLY ` ,1(- Appgeotlon Accepted By Date�" � Mw o6 Grout Iropectlon By Date Pimp Inspection By Dote Deat,miten Impectlon By Dote •� 76 ///��._Q\\ Cemmer.tr t/ 07L/5 �- ACCOUNTING ONLY: AID# FACE PE CODED FEE INFO AMOUNT REMITTED CHECK#MASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE r Pub.Health Serv.-Enviro.173(3/96)