Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER. S PAYA(i N'6 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, W4 EAST WEBER AVENUE, STOCKTON, CA q j w FkF.CElVED <br /> (209) 468.9420 DEC 1 4 14 y5 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JCi,,y 111N Cl;,1NTY <br /> (CDRPIBte In TriPlintBl PUBLIC HEP..0 H .S PRVICES <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 6 MADE INCOI <br /> NVIOtl ,.'A41- i DlE I ION <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-111$.3 AND THE STANDARDS OF SAN JOAQUIN CO NTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH IN N. <br /> JOB ADDRESS/OR AM, CITY 1 <br /> OWNER'S NAME GI 1 y`�1 L.�O1T PARCEL BRE/ARIL t' <br /> ADDRESS (�)� f PHON <br /> ` COMPACTOR I,, �a' ADDRESS NLzoCP�ivt lFtyRri `L•tlC�� 33•..0?�+`� <br /> f SUBCONTRACTOR /�^ In�.MEMS PHONE ,XJ- <br /> I- H ADDRESS �U LIC#6L PHONE I �Tf <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I OTNEfl <br /> r ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑RoPw, H.P. DEPTH RUMP SET FT. FIRST WATER LEVEL 0 <br /> RYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# SIL WFUNG B <br /> ❑DESTRUCTION: I — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION-. A <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/RSVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEL/PVC DIA.OF WELL CASING 0 <br /> ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRPOATION/AO ❑OTHER GROUT SEAL INSTALLED BY 1 GROUT BRAND NAME E <br /> ❑ MONITORING /D I GROUT SEAL PUMPED: 13 Y. 0 N CONCRETEPEDESTALBYDRU-MOY. ❑Ne S <br /> APPROX.DEPTH L/ LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTRUCTION/OWWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEFI�r'T. ��Y` <br /> I HEREBY CERTIFY THAT;HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> i THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERNFlES <br /> THE FOLLOWIN 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' E A CA WT CALL 2A 11QUR8 IN ADVANCE FOR ALL REQUIRED 1 TIONS T 1 11BBJ{tS. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIImE% -'��� Tltle I Sri <br /> V FL D <br /> ROT PLAN OPE m Betel 6uh�_'te�� I <br /> 1. NAMES OF STREETS I R ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE <br /> EWA SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> law <br /> � SL ' <br /> O - J1S'tr� 6d r <br /> DEPARTMENT USE ONLY G G <br /> ApPllcstlen AOeepteJ BY ° k Date 3�6(D' Ar. - <br /> Grow Impaction By - Date Rapp Impootlon By Det. <br /> D.tr.Ilen Impeetlon By <br /> Date �-{> <br /> ur e <br /> TrAOUNTING ONLY: AID# FAC# 5 6 I <br /> �CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Jt71 g .all ��� coy(4 <br />