FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVIc4 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 904 EAST WEBER AVENUE, STOCKTON, CA 55201388 (2091489-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED TrIpl APPLICATION 18 HERE EL MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUUCTIANDIORI INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WITH BAN .1115 JOAQUIN COUNTY pEVELOPMENT TITLE,CHAPTER 8 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADUf1ESS/ORAPN2 6644 6M ARcADERo b2/V� THC PEGASUS Grzoup crrv- STo 5TO n/ PARCEL 8IZE/APNI OWNER'S NAME THC J)A✓/SR PkES/OeNT ADDRESS WABL AUPCJ2 Ea ASA Q Si0 CONTRACTOR Vw- W DRILL/NG /n/G. P.O. oX S/ 6 PHONE q3�- oR/o COAtSO L Tq NT ADDRESS_ RJn 1//S 7-A A 9457/ikar �Ani 7S PHONEE.374 2RIS" BNB BMMDiOR ,DA vA/E G_ /-(j/�/z YY� 6 T ADDRESS RKEsk/Sf EGA 9 306 ucI 44 cG- 8os / rte/ �^ PHONE l R'JZ-/3Iq TYPE OF WEL1/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL w MONITORING WELL♦ .J V64 LS ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR 2//dl6l YH. ❑ VAPOR EXTMCTON WELL f 11 J N.O Pwelr H.P. DEPTH PUMP SET FT. 30' 7.b.' FIRST WATER LEVEL RVPE OF PUMPD ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ BOIL BORING B DEBTRucnoN: CCO D NG TOC 2 CA WellSfu,l rCIS J9 / 7� LI R U!L AF CRO TFA IA/A ac µ CFiM1'I FA/T d INTENDED USE TYPE OF WELL CONSTRUCTION BPECIFICATIONB ❑ INDUSTRIAL ❑OPEN BOTTOMA DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 11DOMESTIC/PRIVATE 13D GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION B ❑ IRRIGATION/AO 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yw [IN. CONCRETEPEDESTALBYDRILLER:❑Yw [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S MOPOSED CONSTRUCTION/DIOWNU METHOD: MUD ROTARY AIR ROTARY AVGER CABLE OTHER- 1 HERESY CERTIFY THAT I HAVE PREPARED THIS AP'LIOATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 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 CAUFOMIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEB THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOHIORAN'S COMFFNSATION LAWS OF CALIFORNIA.' T PPICANT MWT CALL 24 HOURB IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1204H 4Y411423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blow X JiLI.`I� � R G. Title CO/✓SULT//✓/ (rEOGDG/ST D.t. //-.2D-'77 Oi PAN ID,.b SWeI Seale '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 SYBTEMB. 3. DIMENSIONED OUTUNES 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 WAU(S. ON THE PROPERTY OR ADJOINING PROPERTY. - MW-7� MARSH / i i� MW-6 -- HP-9 FOURTEFN-MILE CEINDOMINIUMS SLOUGH HP-3 HP- BUILDING w,J� P-2 BUILDING � MW-8 GATE HP-10 LIMITS OF EXCAVATION - PLANTER (BACKFILLED 5/94) E ISLAND NTRAly Ce EMBA OFFICE �R/1'EA�ERO \ MW-4 RESIDENCES I 11 DEPARTMENT USE ONLY /n APPlieetlen AwwteE BY >J Deta Arr Grout Imneetlen BY Dote Pune ImPwtlon BY Deb Dwowlon]m,.tlon BY Det. Commwb: ACCOUNTING ONLY: AID# FAG PE CODES FEE INFO AMOUNT REMITTED C ABN RECEIVED BY DATE T/SERVICE REQUEST NUMBER INVOICE SS w— too