SU0001285 - Laserfiche WebLink

Home Browse Search

PAYMENT - RECEIVED APPLICATION FOR WELL/PUMP PERMIT 1 92009 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION N AQLAN COUNTY 304 EAST WEBER AVENUE, STOCKTON, CA 95202 u LTH SERVICES (209)468-3420 ENVI EN .HEALTH DIVISON NDN-REFUNDABLE PERMIT EXPIRES 0 YEAR FROIIE DATE ISSUED APPLICATel ION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEP.MIT TO CONSTRUCT IANDIORINTBTALL THE WORK DESCRIBED.THIO APPLICATION IS MADE 1N CDM CE NRTI{SAN JOAGUIN COUNTY DEVELOPMENT jTFFLE,,C4HAPTER 9-1 115.3 AND THE OTANOARD$OF OAN JOAOUIN COUNTY PURLIC HEALTI4 SERVICES,ENVIRONMENTAL HEALTI4 DIVIS JOB ADORESSIOR APNI $ C d t� uj, f / ,�r .� CITY , f s3 PARCEL 81ZE/APN/ OWNER'S NAME f f,' if ADDRESS [/4/ f :}SITGNE R CONTRACTOR ADDRESS ( 7 UC! PHONEI RUB CONTRACTOR- , ' ADOfiE68 UCI PHONE• �y a TYPE—OF WELVPU,MP: E NEW WELL .,❑ REPLACEMENT WELL ❑ MONITORING WELL'f ❑ OTHER ❑yL INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL yE,Now©Repdr H.P.�.� DEPTH PUMP SET . FIRST WATER LEVEL--�� - 7 O HYPE OF PUMPI ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ ROIL BOWNG - S ❑DESTRUCT ION: IMTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS A ❑ IMMOTMAL ❑RPEN BOTTOM DIA.OF WELL EXCAVATION GIA.OF CONOVCTOR CASING p j ❑ DOMESTICIPRIVATE 11 GRAVEL PACXIMZE TYPE OF CASMOISTEEUPVC DIA,OF WELL CASINO p ❑ PUBLICIMUNICIPAL 1_I OTBVEN OEPTH OF OROIrr SEAL SPECIFICATION R ❑ IRRI ATIONIAG ❑OTHER GROUT SEAL INSTALLER BY GROUT BRAND NAME E '❑ MONITORING GROUT REAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. ONO S APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE 3 PROPOSED CO NSTRUCTIONMAILEINO METHOD;'MUD ROTARY AIR ROTARY AUGER CABLE OTHER ' 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK V41U BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULEB AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18IBBIIED,1 SHALL NOT EMPLOY PEFWN$MMJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.• CONTRACTOR'@ HIRING OR SUB-CONTRACTiMG SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 18BVEO,1 SHALL EMPLOY PERSONS BVBJECT TO WORNMAM'S COMPENSATION LAWS OF _ CALIFORNIA.' THE A!A PCANT MUST CALL HO 1N ADVANCE FOR ALL R£OUNIEO iMSPECTIONO AT 92")449,9423,, COMPLETE DRAWING AT LOWER AREA PROVIDED, y/ .Sb X— --✓� L� r TIO* w/L�-�'F Drtr ''/(A — �1 L� �I i PLOT PLAN(Grow to Do*I*$Sado •to 1. NAMES OF STREET@ OR TIOAOS NEAREST TO OR BOUNDING THE PROPERTY. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,ORMIO DIMENSION$AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTUNF.8 AND LOCATION OF ALL EXISTMO AFM PROPOSER S. LOCATION OF WELLS WITHIN RADRIB OF ONE HUNDRED FIFTY F F. STRUCTURES,INCLUDING COVERED AREAS SUCH A@ PATIOS,OW VEWAYB,AHD WALKS. ON THE PROPERTY OR ADJOIHIIO PROPERTY. I I f ,4i _ . 1 4_1 ..r.... ..... i. ' .................. .. .... .� -.v...,. _ �D�� NLY Applloolion AraoMod By (2�. � D*lo /e0e) Arr Grein Impeallon BT Soto PO.P hvprtl*n By Dole Oe*ealrallen In•poetkM 1346 oofa q I Coremerrt•�- I "L2'?BTU fJFl.t.. /s I*A+�" F r'b r3+� - f ACCOUNTINO ONLY- AID/ FACA PE CODES FEE INFO AMOUNT A iED C ECK/ SH RECEIVED BY DATE PEP1YtITISERVICE REQUEST HUMS�I INVOICE �Sb050 5—z) LL3t 110 S1�OCA e't 'I