SU0004370 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SEL ENVIRONMENTAL HEALTH DIVISION I ; r P 0 BOX 368, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.386 �t {209] 468.3420 j tj 1.. 1 9 1995 i NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Tripl'Ioat@) I: DIIRR�O11NMT' ENTAL�[HEALTH 1I APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DE@CRIe�SIRBa�Tjg�j�g MADE IN COMPLIANCE WITH BAN -JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER$-1116.3 AND THE STANDARDS OF SAN JOAQYIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOREBS/OR APN; -7414`1 W• 114, ST. CITY/ M AC PARCEL STLEIAPNN �J D—7-M'CA-'• i' OWNER'8NAME FRA14K COELI O —44 +i11 ap"Z4Z�. ADDRESS W 11 Sf`IT7�1C 953 ?' CONTRACTOR V f V� DR S LLti (� P p,Dp1C sf R I 0 vl SrA cA 945 uC.658lS b fro N'3-44-7-915 ADDRESS SUS CONTRACTOR - ADDRESS Lice. PRONE# TYPE OF WELLMVMP; WNEW WELL ❑ REPLACEMENT WELL .rMONITORING WELL; <<a` +3 ❑OTHER - y ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSa-CONNECT REPAIR - - ❑VAPOR EXTRACTION WELL# ❑New❑Repair H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL.' p (TYPE OF PUMP) - © OtTT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL# © @OIL BORING 0 ❑DESTRUCTION: . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 1:1 INDUSTRIAL ❑OPEN BOTTOM GIA,OF WELL EXCAVATIONC$•t�dry DIA.OFCONDUCTORCASINO_N�A A 13DOMESTtt nwvATE 11ORAVEL PAC%ISI2E TYPE OF CASING/STEEUPVC 7G G DIA.OF WELL CAMM 'Z t�►! D 13PUBLICIMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL S/ SPECIFICATION s ❑ inroax tON/AO OTHER - GROUT SEAL INSTALLED BY V+W QAOUT BRAND NAME t= T EM ENT { ® MONITORING +� GROUT SEAL PUMPED: CQ Yee ❑Ne CONCRETE PEDEBTAL SY DRILLER ❑Yw ❑Ne S APPROX.DEPTH !/t/��U . LOCKING CHESTER Bo%!STOVE PIP£ _ a: PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHB.._ I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALFFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTINO SIGNATURE CERTIFRE4 THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'a COMPENSATION LAWS 0� CALIFORNIA,' THE APP1UClANMMU LL 2A HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION@ AT 170@)4!@Ji27, COMPLETE OMYYINO AT LOWER AICA PROVIDED, Signed% . a., A� - - C ols-r C xx�,ytc/'r�T»cH1-�csfi .D.t.--- -f to lc:55 ._,. '�1 TNIs �j - PLOT PLAN 10raw to Saeiel Seel* 111 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUBC SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BySTEMa, 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL8 WffM RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, .. ••a r 0 .. .. .. .. b:ai. ......- ..... .... - - .. - :;.. l..,...: T I .. . �. , .. . U . .. .. .. .. : : : : ....... .14& .. ;.. ..... . DEPARTMENT USE ONLY Appllaetlen Accepted BY Dirta Grout Inspection By Date Pump Inspection By Dart* DaMnwtlon Inspection BI By— Det Comments, I Fr .......... ACCOUNTING ONLY: AID# FAC; PE CODE@ FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By DATE PERMITISEIMCE REQUEST NRAMBI@t INVOICE } I