Laserfiche WebLink
*� APPLICATION <br /> --- FOR WEL P <br /> L! UMP PERMIT 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> T ENVIRONMENTAL HEALTH OIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CamPl <br /> in <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAdUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HERE LTH DIVISION. <br /> JOB ADDRESS/OR ApNN i1, I f,. - <br /> CITY PARCEL SIZVAPN,I <br />' OWNER'S NAME t `I' <br /> f M� <br /> ADDRESS <br /> CONTRACTORI'U f�C�C /• ? /.9013 PHONE x <br /> SUB CONTRACTOR i ^ wP. PHONE d� <br /> .61 ADORE-- - ,n, LICJr <br /> 5 h b q,G RHONE )4Q -7— <br /> TYPE OF WELLlPUMP: ❑ NEW WELL ❑PREPLACEMENT WELL <br /> - - <br /> }, �MpNITORING WELL.0 13 OTHER <br /> 11 INSTALLATION El"WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR <br /> [3N.ElRoI H.A. © VAPOR EXTRACTION WELL <br /> RYPE OF PUMP) .+� DEPTH.PUMP SET FT. FIRST WATER LEVEL <br /> ❑i <br /> OQUT <br /> OUT-OF-SERVICE WELL <br /> GEOPHYSICAL WELL s <br /> ❑DESTRUCTION: .g: SOIL BORING - B <br /> INTENDED USE .r <br /> TYPE_ O�p WLLL .f CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION '+j li <br /> A <br /> ❑ DOMESTIC/PRIVATE RAVEL PACKlSZE''' _ OIA.OF CONDUCTOR CASING D <br /> ❑ PUBLICIMUNICIPAL RIVEN TYPE OF CGOUTST 6EALLIPVC {J <br /> DIA.OF WELL CASING <br /> - EEDEPTH - � D <br /> ❑ IRRIGATIONIAG ❑ OF GROUT OTHER GROUT SEAL INSTALLED BY SPECIFICATION <br /> 777777 �� <br /> ONITOFUNG GROUT BRAND NAME `�f l�(1'JC ,'t.'•�YIfi�r A <br /> APP .� I GROUT SEAL PUMPED:Zfe. ❑Ne L E <br /> APPROX.DEPTH • CONCRETE PEDESTAL BY DRILLER:❑Y. <br /> No S <br /> PROPOSED CONSTRUCTION/WIILLING METHOD: MUD ROTARY LOCKING CHESTER SOXISTOVE PIPE - <br /> AIR ROTARY AUGER ^� S <br /> �)i ~� CABLF���,OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFp(WILL BE DONE'IN ACCORDANCE WIT}I ggtl JOAQUIN COUNTY ORDINANC$S,STLAWS,qN0 RULES AND <br /> REGULATIONS OF THE SAN J LL NOT COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CER7'!FY THAT IN THE PERFORMANCE E THE WORK FOR WHICH <br /> THIS PERMIT N ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAL1FpRNIA.- CQNTRACTOR'S HIRING OR SUB-CONTRACTING THE FOLLOWING: '!CERTIFY THAT IN THE PERFORM OF THE WORK FOR WHICH THIS PERMIT i8 ISSUED,!SHALL EMPLOY <br /> CALIFORNIA.' THE APPLICANT MUST C 24 HOURS IN ADVANCE FOR ALL REQUIRED IN PERSONS SUBJECT TO WORKMAN'S CCOIy,IpQyATION LAWS OF <br />'- Signed X \ INSPECTIONS 120914883422, COMPLETE DRAWING AT LOWER AREA PRO IV <br /> TI.- Prl lD t G J. p D k f I. <br /> ill I <br /> Dec. <br /> i. NAMES OF STREETS OR ROADS N PLOT PLAN{Drew to Seale)Sulo to <br /> 2. OUTLINE OF THE PRO � �TO OR BOUNDING THE pROpERTY. - <br /> 3. DIMENSIONED OUTLINES q D LOCATION ONG DIMENSIONS <br /> ALL E7dSTINt,AND NORTH I R CTION. - 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I <br /> STRUCTURES,INCLUDING COVEREDPOSED <br /> EXPANSION OF SEWAGE DISPOSAL 61,gT�g <br /> AREAS SUCH AS:PATIOS,,DRIVEWAYS,AND WALI(S.,..:... _ HUNDRED fl F7 <br /> 5 LOCATION OF WELLS WITHIN RADIUS OF ONE <br /> - - .ON THE PRO.PER7Y.OR ADJOINING PM <br /> APPIIutlon A DEPARTMENT USE ONLY , <br /> arOVt ln*PwUon 8y r 1 Date <br /> Dat.7 /6 !;�PymP Inrpectton By <br />)fttructien IruPectfO„By <. Qat. <br />.ommmta: - - Date . <br /> ACCOUNTING ONLY. AID# <br /> � FACN <br /> PE CODES FEE INFO AMOUNT REMITTED >- <br /> c HEC /CASH RECEIVED 9Y .DATE <br /> P9IMITISERVICE REQUEST N <br /> 005�I 8 UMBER INVOICE <br />