SU0006024 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT- I SAN JOAQUIN' COUNTY PUBLIC HEALTH SEAS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA'MI 188 (209) 468.3420 MOR•RENIIIIABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compkts In Trlplieds) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND(OR INSTALL THE WORK DESCRIBED.T1418 APPLICATION 18 MADE IN COMPLIANCE WtTI4 S/ JOAQUIN COUNTY DEVELOPMENT /TITLE,CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR API# /i�Q L� -r_ 'j.ti•,�e t �� CITY l 7 /� PARCEL SREIAPNI OWNER'S NAME L D/ U r' /7 r ADORE6S N /', 7 PHONE t CONTRACTOR v ss:. ADDRESS !�+! AaIr -'-7//";I LIC#—(&2f SUB CONTRACTOR ADDRESS_ �LJ�.,,, �u /{e UCN PHONE ',. TYPE OF WELL(PUMt ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i c�.b tFNew 13Repelr H.P. DEPTH PUMP 8ET�FT. FIRST WATER LEVEL (TYPE OF PUMP) ❑,OUT•OF•SERVICE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL SORING f ❑DESTRUCTION: - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO L ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CA61NO L ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME --y £ 11 MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee []No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED COMMUCTIONIDRILLINB METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER --- I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORD WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN 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 WHIC THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE-OF-THE WORK.FOR WHICH THIS PERMIT 18.188UED,I SHALU EMPLOY.PERSON@ SUBJECT TO WORKMAN'S COMPEASATION LAWS O CALIFORNIA.' THE CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTI��OpN'S��A//T��I20014"-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Title D Signed x �1 �. _ • ->/W ! k? ate PLOT PLAN(Grew to Saala)Sgala "to 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 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY87EM8. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. - ��. PAYMENT JV : r� : . . . . .....,. . E C r7 � ... _ SRN l {I�ir r QTY _. ENVIRON O AL:Hl >�i rl.lw)I�1.QN ....: .. J . u :. DEPARTMENT USE ONLY -, Appllostlen Aaaepted Greet 1r>•pec"on BY - ate Pump Inspaetlon By ; Date 7 y�7 -- i Dastruetlon Impaction By Date Comments:_ WertSeAzew 6y /Yr"r4~L f--. ,efi +qI ACCOUNTING ONLY: AID/ FgCg PE CODES F AMOUNT REMITTED EC /CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE ia2 7 _ 1