FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION! FORWLLIPUMP PERMIT SAN JOAOWN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOOKTON, CA 9520E.388 (209) 468.3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Womploto IB Tykileots) APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 116.3 AND THE STANbARDO OF SAN JOAOUIN COUNTY PUBLIC HEALTHSERVICES,ENVIRONMENTAL HEALTH ORAeroN. JOB ADDRESSOR APNs �7�Ty-It+ far�1'O-{,yY— ��7 _Cir/CA PARCEL SIIZZEF/AAPNR OWNER'S NAME-JO)n fT_5�7JVFY - P r'-'s t `` / ^�,,,�� AbbRItE88 �a [T Ll� PHONE I• 1�+ 'n Ca11TRACT0R L^[Y-(7u LLt V ��S�Y�(i ...— ADORESB C f w _'r� ��7 sl�[JY'�d-•� Fw1DNEM�`I��3-31-)$'� OUR CONTRACTOR AbbFiEes cl.IC• PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRoRING WELL v ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I RYPE OF PUMPI 13Naw❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT•oF-SERVICE WFu ❑ GEOPHYSICAL WELL/ SOIL BORING find 6l fl— S ❑OEBTRUCTION: INTENDED IBONiTRVCTION E TYPE OF WELL C6PECIFICA11OMS A ❑ INDUSTRIAL ❑OPEN BOTTOM ORA.OF YNELt• 3 T�-G��s DIA.OF CONDUCTOR CASING ❑ rrp DOMESTICIPRIVATE ❑GRAVEL PACKMIZE TYPE OF CASING/6TEELIPVC VIA.OF WELL CASINO "I'll" p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION O&AN ❑ NRRIaATIONIAG ❑OTHER GROUT SEAL INSTALL Ep BY 0 w GROUT BRAND NAME !1 e*'4 E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. gNe CONCRETE PEDESTAL BY DRILLERS❑Ym ©NO S APPROX,DfDTH t LOCKING CHESTER BOXISTOVE PIPE/ S PROPOSED CONSTRUCTIOMIDMtLTNG METHOD: MUD ROTARY AIR ROTARY AUG-I;R-__ ,jL CABLE OTHER 1 HEgEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH-9@AN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CE#TTIFIES THE FOLLOWINO,'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU 1 SHALL N07 EMPLOY PE S SUBJEC TO WOR CMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 6UB-CONTRACT1NO SIGNATURE CERTIFIES THE FOLLOWING: 1 C RTIFY THAT IN THE O ANC �0 H ICH THIS PERMIT 16 ISSUED,I-HALL EMPLOY PERSONS SUBJECT TO WORKMAN,COMPEN ATION LAWS OF CALIFORNIA.' T A CANT MUST CALL P ALL REOUIRED INSP PEECTION-AT 12001 4pJ427. COMPLETE DRAWINO AT LOWER AREA PRO DED. Blerrsd X Tltla R C' ��/� on. PLOT PLAN 13rno to 90.1et Semi* •le 1. NAME-OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED" 2. OUTLINE OF THE PROPERTY,GIVING DIMENMONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 01043OAL SYSTEM6.-� a. DIMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAVIUS OF ONE HUNDRED FIFTY FT. OIRUCTVRES,INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINMlO PROPERTY. I DEPARTMENT USE ONLY 6W 9 ApplicationAooa D.1._ ! A,. GreLA Impact;" T bate Rmp In.peallon BY onto Dntrmtien Imp": an V bate f Commov'gw ACCOUNTING ONLY; AID/ - FAG PECOVES FEE INFO AMOUNT REMITTED CHECK+FICASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE L Pub.Health Serv.-EnWO.173(3196)