SU0005665 - Laserfiche WebLink

Home Browse Search

/ /�✓� APPLICATION FOR WELL/PUMP PERMIT �! r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ` (209)468-3420 j NON-REFUNDABLE PERMIT EXPIRES f TEAR FROM BATE ISSUED (CBmplete le TrlpReatal APPLICATION 18 IIEPE BY ADE TO THE BAN JOAQU1N COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN JOAQUIN COUNTY DEVE I MENr TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. JOB ADOFIESB/OR 1 JJD— CRY l PARCEL SIZFJAF`Nf OWNER'S NAME ADDRE88 �y��P110NE CONTRACTOR ` ADDRESS yx 1]CI /u.1/ PHONE I SUB CONTRACTOR ADDRESS LICS PHONE JYPF Or WELUPUMP: ❑ NEW WELL ❑ REWLACEMENT WELL ❑ MONITORING WELL IF ❑ OTHER ❑ INSTALLATION ❑WELL SY TEM REPAIR ❑ CROR8-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 ,/ ❑Nov C)Repe6 H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O (7 YPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ OEO SICAL WELL Jr NMI.BORING 8 INTENDED USE TYPE OF WELL CONSTRUCTION-SPECIFICATIONS A � ❑ INWBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CANING 0 ❑ DOMESTICIPRIVATE ❑GRAVEL PACKINZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CAMNO p ' ❑ PUSLIC/MUNICIPAL ©DRIVEN DEPTH OF GROUT BEAL SPECIFICATION q I ©-tRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: [IV. ❑Ne CONCRETE PEDESTAL BY DNLLER:❑Yee [IN. 5 APPROX.DEPTH LOCKING CHESTER SOXISTOVE FS$ S PROPOSED CONSTRUCTTONIDRItLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I IIAVE PREPARED THIN APPLICAT1pN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATION8 OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTB-Y THAT IN THE PERFORMANCE OF THE WORK FOR WMtCH THIN PERMIT IN ISSUED,I SHALL NOT EMPLOY PERBONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BIIB-CONTRACTtNO SIGNATURE CERTIFrE1 THE FOU,OWINO: .1 CERTIFY T T IN TILE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 188UED.I SHALL EMPLOY PERBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF v CALIFORNIA.' THF ANT T CALL MOURN IN ADVANCE FOR ALL REQUmm INSPECTIO AT 12081 4MJ128. COMPLETE DRAWING AT LOWER AREA PROVIDED. 01 � Blvned X Title - _ Del.--- s d[. .� PLOT PLAN IDrew to Baprel Seale ^to I. NAMES OF STREETS OR RoApe NEAREST TO OR SOVNWNG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y9TEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVIFrO TRMENWONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 8. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED IF. LOCATION OF WELLS WTTWN RADIUS OF ONE HUNDRED FIFTY FT. BTRUCTUREB.INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. C�7 I i i ry - S►0 rt. ru ., I 1ENT.I AUG.... 7 1998 -SAN JUh Lli COli�7Y"r"' PLIBUC H LT SERVICES I L-N.�RITH.F,?4V1.SIC.3lv.;..... DEPARTMENT USE ONLY /I Applieetlen Aeeapted By --!. to)Is Mw -. Ot6ut tmpeatbn SY Dela Ptwnp Inwpeetlen By Dete Oa t.ttden Impe Don BY Ot. Cetnmems: i ACCOUNTING ONLY, ALO# FAIT I PE CODES FEE INFO AMOUNT REMITTED CHEC !CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE I Pub Health Serv.-Enviro.173(1/971