SU0003584 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRES=R APN# 17000 E, RW 1 1 20 CRY RIPON PARCEL SIZFJAPNR OWNER'S NAME THE WINE GROUP ADDRESS P.O. BOX 697, RIPON, CA 95366 PHONE# 599-4111 CONTRACTOR NORCK PUMP CO. ADDRESS STQGKTgp1 I g UC# 504513 NE# 948-8817 CA 1�110 SUB CONTRACTOR ADDRESS LRC# PHONE# TYPE OF WELL/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 11VAPOR EXTRACTION WELL ,I -URB INE_ 11New 3 Repair H.P. DEPTH PUMP SET_q LIT. FIRST WATER LEVEL 4E O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: ENTENOLiD USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '-' '-- A I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ll) IR DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIFVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG, ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER.❑Yes ❑No 5---^ APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE g� PROPOSED CONSTRUCTIONPIMLLING METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY 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 FOLLOWING:'I CERTIFY 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 CERTIFIE THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-41 COMPENSATION LAWS O� CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN A ANCE FOR ALL REQUIRED IN N8 -12091 3423. CO E DRAWING AT LOWER AREA PROVIDED. Signed X Title fa,", Date_ r r� PLOT PLAN{Draw to Scale)Scale 'to 1, NAMES OF STREETS OR ROADS NEAREST 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. Y STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. " E...... ., - ... _ __ ................. .......... ......... ........ ...........N. .......... .............. ...... ......................................... ................................. .......... ............................... .......... ....... . . .................................................... ................................................................................... ............................. .......... .... .. ....... ............ ........................ ................ ......... ............... ........................................ .................... ....... .............. _ -.-r-.. ......... ......:...... .....:... .......:... . .:..... ........... .. .. .. .. .. ...... .......... ..... ......... .................. .......... .................... r ......................................... ., . ....... ............. 06 ................. .. ... ... ...... .. .. .. .. .. .. .. . . .... ... ... ...... ............ ......>........ ... ........... .. . ya r ; DEPARTMENT USE ONLY !',� Y .:�-.iJ -i i - Applicatlon Accepted BY Date 3 Are. Z Grout Inspection By Date Pump Inspection By Destruction Inspection Ey Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED 012Q!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE ✓ 1i