FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

AP l i A !6N I'DR >yELLiPiJfli? PERMIT If JOAUUIN COUNTY PUBLIC 4EALTH SERVILE ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 3C4 E.yB T WESER AVENUE, STOCKTON. CA 95201388 (209) 463.3 -3 r'0fUAf1f0k0A8Lf 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# ` I)gZ- C_ & t il/ CRY �T"o�(L � _ PARCEL SIZE/APNS OWNER'S NAME �G- L' I" ,o", b'W ADDRESS/0 C�p S• 14-1, GL!� -t^ll+� N"� f S�'L �.-� U✓t�/d L-�✓ PHONE? `Zt 07 77-77/-5 / -y- �S7 ,wig r _ � 0 Lu ) F/,,,,-CONTRACTOR FI✓ �CL�/1_/•1�/Cs- / ,� ADDRES�Gr`F(-,4L �/ }ic# PHONE# 70-- "'740 SUB CONTRACTOR f/(�rt'�T C�t-�t�'f- ,�,^/r/L{p, ACDREss t��{.-� L6'•7,�-�,.:.y 1�4?_7z1')J1Cr,$--��"'�`I i ( P'HONE a, - 7Z�C TYPE OF WELLlPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repelr H-P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B DESTRUCTION:�F-✓- -.L� N-..LL.i N/!rl r-(lit !//✓yL G�/- 7 rv/C/O-L !'i�� /O vC `7'L' S(-O �( 41 A+ n /Ile INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS D�Sv( G / (� ty� (�C A ❑ INDUSTRIAL ❑OPEN SOT-TOM DIA.OF WELL EXCAVATION ^ (/ DIA.OF CO;4UCTOR CASING CLN..(.c.�� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING 0 ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Vee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIP£ S PROPOSED CONSTRUCTION/DFJLUNG 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 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR 1NH!C. THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOR TN CANT MUST CA�F�OURS IN Api.�C'<"t7 Ai�n:jtt ia' �HAPECTIOtit AT 1200 4 .3123. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X 4rL'L�-- Tltle �/ZL (/ CL'�1.� 7 PLOT PLAN SDrew tp Sole)S—ie '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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY / n L,t9 ep Applicstlon Accepted By ' s� 0*KGrout Irnpectlon By Det Pump Impxtlon By Dat.- Deet,—tion Irnpeetlon B Commenter ,A ACCOUNTING ONLY: AIDS FACA PE CODES FEE INFO AMOUNT REMITTED CHE # ASH RECEIVED BY DATE PER/MIT/SERVICE REQUEST NUMBER INVOICE >J vz !� '65