SU0003584 - Laserfiche WebLink

Home Browse Search

f n' APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICia- ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 458-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compute in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, - JOB ADDRESSIOR APNM_1 70M CR lv(yal�n �.CITY��fJ/0G� /�._., n PARCEL SIZE1APNM OWNER'S NAME [.v ADDRESS fbjdx R]T ISJI.�IAJ. C.Ei r PHONErf �� CONTRACTOR ADDRESS+SW��// �Ii�i�� JJ�LIC �z�PHONE N!7 SUB CONTRACTOR ADDRESSV", T �G/ r L1CN PHONE N TVPE OF WEu TumP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER �^ ❑ INSTALLATIO ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N J ©New L9 Re4tair H.P. DEPTH PUMP SET/,�-,&FT. FIRST WATER LEVEL p PE OF F'UMPpy QN QIrL � ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLN ❑ SOIL BORING B ❑DESTRUCTION: 44 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING O O © DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D CJ ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R C ❑ IRRIGATION/M ❑OTHER GROUT SEAL INSTALLEO BY GROUT BRAND NAME E �1 ❑ MONITORING GROUT SEAL PUMPED: ❑Ya ❑No CONCRETE PEDESTAL BY DRILLFR:❑Ya ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONSTRUCTION/DRILUNG METHOD. MUD ROTARY AIR ROTARY AUGER CABLE OTHER r I HEREBY CERTIFY THAT 1 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES N THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T UED/� CANT MUST CALL 24 HO ADVANCE FOR ALL REQUIR :ECTI HS AT f 1 4 23�. �MJPLE'fE DRAWING AT LOWER AREARIVED. I Slgned X _ -TI e PLOT PLAN IDraw to Seale)Seale '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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. .. .... .....-, .... „ ...... .,... .. --. ....;.., ......., ... ., .,.. .. PAYMEN .. . ..... .,. . n95r : i ....... bRN J................I 1 ... .. - L7N;5 EN Uf Chu.... f tN �fft N AL. i.EA�.r {.�jl�i5la7....{ C1C .. ..... .. . CNNfE € 4Iw - Zv FN,2+p► .... w+ .. : ....... .. . .. :... . .. . :............................ ... ......;...... .. . . . ......... . . . ` DEPARTMENT USE ONLY 1/�� / Application Accepted By J(1,9 , Area �+C Grout Impaction By Date Pump Impaction By Dat4a*/ Dmtructlon Impaction BY Data E Cammenta; ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFF�O� AMOUNT REMITTED HEC /CASH RE Y OATS PERMIT180MCE REQUEST NUMBER INVOICE t� r an, . OM2 00 -ZMr raj I