SU0003865 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMF._ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I 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 9-1115.3 AND THE STANDA SOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AI ` CITU PARCEL SIZE/APNI OWNER'S NAME ADDRESS ////``` PHONE X CONTRACTOR DDRESS LIC#-� PHONE♦ SUB CONTRACTOR ADDRESS LICA' PHONE X TYPE OF WELUPUMP: aNEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IV ❑ OTHER ❑�/INJLLLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A (TYPE OF PUMP) U7 New❑Repeir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL d ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TTYY�PPEE_g �ILL CONSTRUCTION SPECIFICATIONS �� A ❑ INDUS�IAL OLLC PEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p = lhY6p/MESTICJPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINGy O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ya I{J'No CONCRETE PEDESTAL BY DRILLFR: Yee ❑No S' APPROX.DEPTH � LOCKING CHESTER BOX/STOVE PIPE, S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE ✓ OTHER U 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,I 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 RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THEA CANT MU T C 4 HO IN ADVANCE FOR ALL REQUIRED INSP IONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. � -, Slpned X � z Tltle � Dete PLOT PLAN I ew to Scelel Scele 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PR PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIREC ION. 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. K ............ IN4 .......... � o ....''PAY, 9EWf R �'�' JUN SAN JOAclu >L,,4 PUBLIC HEAL.i H -SERV!C S pON,MF ITAL HE DEPARTMENT USE ONLY Appliutlon Accepted By Dete S Aree � Grout Irnpection ByMe !JPiin, ' „_•_