SU0002737 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WEWOUMP PERMIT SAN JOAQUIN COUNTY PUBLIC OATH SERVICES J..,' ENYIRONIkIENtAL HEALTH 01VISION = '�'`� P.O. BOX 3f38�304 EAST WEBER AVENUE, ST'OCKTOi� CA 95201.988 (109) 469-3420 NOR fFUNQ�BI pERMfT EXPIRES YEAR FROM BATE(88UED (Complat6 In TrlpHeati) APPLICATION!S HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT Mom INSTALL THE WORK CESCRIBEO,THIS APPUCATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1116.3 AND THE BTANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMEMAL HEALTH DIMS/ION. JOB ADORESBYOR APN#L ..32 jr r�� Cir C,(J D! PARCEL StZE/APN/ OWNER'S NAME r "O t] �/yLfL — ) ADDRE66 ds�oss DREPHONE CONTRACTOR k �-'I T o AD88 0 - R 17 3773 d r PHONE R33L y?V E SUB CONTRACTOR `3� L s u s' ADORES e S` LIG/ ' .�,,._,��PHONE rte^.. TYPE OF WELLIP IMP' f NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r ❑ OTHER ® INSTALLATION ❑ WELL BYBTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r S- % ❑Now©Repair H,P. DEPTH PUMP GET—Ft. J (TYPE OF PUMPIFIRST WATER LEVEL ❑ OVT-OF•BERVICE WELL ❑ GEOPHYSICAL WELL r�� ❑ edit BORING „'e 8 ❑DESTRUCTION: INTENDED USE TYPE OF W CONSTRIJC 0 iPECIRC 0 ❑IHbUBTRIAI ❑OPEN BOTTOM A DIA.OF WELL EXCAVATION_ I O DIA.OF CONDUCTOR 6A61Nq . ❑WLIIEBTIC1PRtlVATE ❑GRAV�LPACKl81ZE mss+ p A ^1 TYPE OF GABINOISTEELIPVC - !�" OAA.OF WELL CASTNO . . f7 Pu8L1CIARUNICIPAt 11 DRIVER DEPTH OF OROUT BEAL So +�IRRIDATIONlAG ❑OTHER SPECn'IGATION E� GROUT SEAL INSTALLED BY.. ICO 511'\ _ - GROUT BRAND NAMIF YYe�tt ❑ MONITORING GROUT BEAL PUMPED-My., ❑Ne CONCRETE PEDESTAL BY DRILLER:•4,J Yaa ❑Ne i APPROX.DEPTH �� LOCKING CHESTER BOXIBTOVE PIPE PROPOSER CONSTRUCTIONIMLLING METHOD: MUD ROTARY_ x _p1q RpTARy S AUGER CABLE OTHER,._ 1 HF9E4Y CERTIFY THAT i NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER ANtr: RIEGULATIONB OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGE 18 SIGNATURE GERTIFIEB THE FOLLOWING:`I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH1C THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WOFrKMAN•i C4MPEN8ATION LAWS OF CALIFORNIA., CONTRACTOR'8 HIRING OR SUBCONTRACTING BHINATURE CERTIFI£ THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMFT IS ISSUED,I SHALL EMPLOY PERSONSACR'SUBJECT 70 WORKMAN'S-COMPIDNATUAN LAWS OP CALIFORNIA.' THE APPLICANT MUi7 CALL 24 h104JRS IN APVANCS FOR ALL REQURIEp INBPECTONS AT Roel 4404422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Stoned X. Title Data i PLOT RAN(Draw to Beatat Scala 'tti _ 1. NAMES OF 8TREET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE blBP08AL SYSTEM OR NIIOP08ED y 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH bIRECTION. ' EXPANSION F SEWAGE WAGEINGMAL SYSTEMS. 3. DIMENSIONED OUTUNP,$AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WIFLLB WITHIN RA L S T ONE HUNDRED FIFTY FT,- BTRUCTUREB,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR/ADJOINING PROPERTY, i _-... V ., i... x... w a JUL 2. JU' A Y FPI VfRC11�f i HSEf�VfG'"� DEPARTMENT USE ONLY K i Application Accepted By Data `Z Arae _Z��r Grout Impaction By r f/ beta Pump Irupaotlen By Date i baetrmllan lrwpwtlon BY IV t Data Cemm&mc ACCOUNTING ONtY: AIDr FACT F7 .......... PE CODES FEE(HPO AMOUNT REMITTED HEG ICABN RECEIVED aY DATE PEW TISERVICE REQUEST NUMBER INVOICE b 03 (s 0 3 r X55"