SU0004493 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT PAYMENT SAN JDADllIH COUNTY PUBLIC HEALTH SER11...a3 ��C�O�� ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201,88 APR 0 2 1995 (209) 468.3420 SAN JtOi,,gUiN CC}LINTY PUBLIC HEALTH SERVICE$ AOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL_HEALTH DIVISION. JGemplete In TriplieBTal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WIT1i SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDR£SWOR APNI_Z �� /_//1V/-Z� Z !`CLF CITY 1{. Kai (i�,--[ -�2(, PARCEL SIZEIARN# OWNER'S NAME rLf I e ) ,041 4--e I'�(� ADDRESS �� //. �`J y�PHONE I�J� 70�Oy CONTRACTOR �. _rte,r J{U pLC/-7/Q J�J"-'(J 1 [ ADDRESS e I R /191/111- 1! L]C1 �5 r PHONE I SUB CONTRACTOR ADORE58 �, �C J] 2 LICK PHONE! TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r ❑ OTHER ❑ INSTALLATION ❑ WELL SV6 fM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL /0—� b J New❑Repair H.P, DEPTH PUMP SET�FT. FIRST WATER LEVEL \�] O rFYPE OF PUMP? ��``��"--------�� . ❑ OUT-OF-SERVICE WELL C1GEOPHYSICAL WELL J ElSOIL BORING R ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CABIN( D ❑ DOMESTIC/PR7VATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELlPVC DIA.OF WELL CASING �D ❑ PUBLICIMUNPCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONfTORING GROUT SEAL PUMPFO: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S APMOX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTIONfMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:"I CEWIF'Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW$OF CALIFORNIA." THE CANT MUST CALL 24 FU'1 SIN ADVANCE FOR ALL REOLRAED INSPECTI,ONyye AT 1209]409-7423, COMPLETE DRAWING AT LOWER AREA PROVIDED. 8lpnOn ed X n Title V /�! Dote I@ el PLOT PLAN (Draw to Scolel Scale "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 SYSTEMS. 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED 5, 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. NOrT,'. , r ey IV�IIRi,tliNtFl+rT , DEPARTMENT USE ONLY -r Appllcatlon Accepted By Dna ftt At" !% GraInspection BY Date Pump Inspection By i' One nt / - IJ Deetructlon Impectlon By Dna Comment*: ACCOUNTING ONLY: AID# FACS PE CODES AMOUNT REMITTED HE #!CASH RECEIVED BY DATE PE M ItTISERVICE REOUEST NUMBER INVOICE 33