SU0006597_SSNL - Laserfiche WebLink

Home Browse Search

APPLION FOR WELLIPUMP PERMIT i 1 SAN JOAC ;OUNTY PUBLIC HEALTH SERVICES !1 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 368,445 N.SAN JOAQUIN ST,STOCKTON,CA 06201.388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 2 [Complete in TrQEiratBl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRRED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTERLS-111 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE^4SQB AAPN# � m - `9,CI7Y �L y1 p EL SRE)APNN.g �1,, /T'}y,, S ADORES6? • v 1 ` SIZE), `RIO l`1k— _.OWNER'S NAME �.)L. ��+ !'� �' .^e PHONE sd`/'y7 I'� - i CONTRACTOR�tA '•IJ \`,,,,1' �OBESS C?ClaO LV I jI.VJ IR# _PHONE,I V F-BCONTRACTOR � _____ADDRESS �"�'-' LICs PHONE# TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL# ❑OTHER ❑INSTALLATION ❑WELL 7 EM S REPAIR ❑CROSS REPAIR ❑VAPOR EXTRACTION WELL s J New❑Repelr H.P. � DEPTH RUMP SEtAlff FIRST WATER LEVEL !3 c;� O I'll ITYPE OF PIIMPI ❑OUT-OF-SERVICE WELL GEOPHYSICAL WELL4I ❑ SOIL BORING S pay u pL"TROL1fBN: rl"TE"DEI USE TYPE OF WELL CONSTRUCTION SPECIRCAT10N5 A T❑UNDUSTRIAL ❑OPEN BOTTOM DIA,OF VlELL EXCAVATION DIA,OF CONDUCTOR CASING O 3 DOMESTICMRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING O Cl PURLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑IRRIGATIONIAO ❑OTHER GRDUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONrTORiNG GROUT SEAL PUMPED:❑Ym ❑Na CONCRETE PEDESTAL BY DRILLER:13Y. ❑Nn 5 APPROX.DEATH LOCKING CHESTER ROXISTOVE PIPE S PROPOSED CONSTRUCTO41MLUNO MIFTHOD:_MUD ROTARY AIR ROTARY AUGER CABLE OTHER 3 HEREBY CEKDFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE CONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND [F7 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 I THIS PERMrr IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES^ THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IRSUFD,I SHALL EMPLOY PERSONS SUBJECT TO WOfOMAN'e fOMPOSATION LAWS OF O CADFORN IE APP MUST CALL 34 HOURS!%ADVANCE FOR ALL RIIaL INePBC710N0 AT 120e1 4ee-7429.COMPLETE DRAWING AT LOWER AREA PRO DED. TC I�'�Slgned X Title Deta rI Cl PLOT PLAN(Drew ee 6cMel Ba+e 'to 4 ` .1.NAMES BEETS OR ROADS NEAREST TO OR BOUNDING THE RIDpERTY. 4, LOCATION OF NO U69 SEWAGE DISPOSAL SYSTEM OR PROPOSED 4 2. OUTLINE OF T"E PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. IV a, DIMENSIONED OUTLINF3 AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION Of V6ELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY.. ...... .... ..... ..... ... ........ L . ... ......... ...... ..... x ... . ... ...... .... .. .. .. ...... ...... ..... . .. ...... .... C .... ...... .. .. ..,,.... i.. ..,.. -- i ...... ..... ....... ...... ..... ........ .... ..... ..... ..... ...... ........... ...... ... ........ ..... . ... ... .... ....... ...... ...... ..... ....... ....... .... ........ .... .. ...... .. ..... ...... .... . ..... - ..... ..... ..... ...... ...... .... ..., ..,,.... ..._ - 3 r L � �7a ...... .... .. . ...... ............. ...... ..... ..., - I I + DEPARTMENT USE ONLY Da Applketion ACeepte4 By ZZ � RIr GtoU In-""ion BY Da P—P InRtention By Oeta / v De.trucvon Irwpactien By Dela - Comments: ACCOUNTING ONLY: ARD# PACs PE CODES FEE INFO AMOUNT REMITTED HEC`/CASH RECOVER BY DATE y PER1,41TISIMACE REOUFBT�NUMBER INVOICE 05&, 5,) �219 ] Y