SU0006328 SSNL - Laserfiche WebLink

Home Browse Search

r. APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON,CA 96201.388 (209) 468.3420 dyO �PIIRIMIT i TEAR FROIl9 GATE ISSUED ripfieatel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUFOR PD/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TR-LE.CHAPTER 8-1115.3 A��NryID THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, � JOB ADDRESSOR APN# - �' CITY_� ,yL, r UI S V,- PARCEL SIZVAPNIf 4 OWNER'S NAME tv-;. V 12 t t 1 ADDRESS s f —� t .�� d — PHO�N E i �I CONTRACTOR , L... ,.ADDRESS -S 0•�LICi.*?. Y�/ PfIONE i—Vd5r�j1 y `r SUB CONTRACTOR ADDRESS LIC# PHONE/ R TYPE OF WELUPUMP: ❑ NEN!WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ I L' ' .❑Naw Repelr H.P. fzQ _ DEPTH PUMP SE t2QFT. FIRST WATER LEVEL_ - I (TYPE OF PUMP) "..— O [3 OUT-OF-SERVICE WELL 13 GEOPHYSICAL WELL i ❑ SOIL BORING g ❑DESTRUCTION: I INTENDED v1:E TYPE OF WELL CONSTRUCTION SPECETICATIONS A I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPWVATE 13 GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVCDIA.Of WELL CASING i' p- ❑ PUBLICIMUNtCIPAL ❑DRIVEN DEPTH OF GROUT SEAL - {gyp sPECIFtcaTwN ,x q IRRIGATtON/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ---� E ❑ MONITORING - ' 'r GROUT SEAL PUMPED: 13Y. 13 Ne CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S per'' APPROX.DEPTH_ _ 2 J b LOCKING CHESTER BOXISTOVE PIPE S r PROPOSED CONSTRUCT10N10WLUNO METHOD: MUD ROTARY AIR'ROTARY AUGER CABLE OTHER 11 I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND t 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEFMfIES THE FOLLOWING: .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN•S COM T10N LAWS OF _ CALIFORNIA.' CANT MUST C .24 ND N ADVANCE FOR ALL REOMED INSPECTIONS AT 12001468-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. _ Slumd X Title aV 5Dete } PLAT PLAN IDrew to Seelel Sole "m 1 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 tNRECTMN. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. _ STRUCTURES INCLUOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY. ' - DECA-5 -1995 ............ HEA Ll Irk . ..... 4 . . ... A, 4 ............................. ...................... ...... ............ ....... ...... ................ ............ . .. . ...... ..... �.. `� ................ . ...........