SU0003984 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WEL.LIPUMP PERMIT r�", SAN ,QUIN COUNTY PUBLIC HEALTH SER\ S -- &ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 I (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED (Complete In TFipliealld APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AbbRE8810It APNI I- .(, f/E A !�� !_ __._CITY �G �•+ PARCEL SIZElAPF1I OWNER'S NAME 1 1 //'' V4 n]-S- y� ADDRESS � J RIONEI CONTRACTOR 1°1 �"I� _ f e -• �•k�l--•--"- ADDRESS 0 C� IJGs' PHONE/O�•�^O�`"� CUB CONTRACTOR ADDRE86 L1CB PHONE TYPE OF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL it J S �❑New❑Repel, H.P. DEPTH PUMP SET Ff. FIRST WATER LEVEL 0 (TYPE OF PUMP) p n let G�.rne- ,!� "� ❑ OUT•OFBERVICE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING B r ❑DESTRUCTION: (` ]. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A `� ,❑ IN/DU MAL ❑OPEN 801TOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D Ly'DOMEBTICIPRIVATE ❑GRAVEL PACKISRE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASINO D ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION N ❑ fRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME •� F ❑ MONITORING GROUT SEAL PUMPED:Ely. ❑Ne CONCRETE PEDESTAL RY DRLLER:❑Yee ❑Ne S O APPROX.DEPTH LOCKING CHEBTER SOX/STOVE PIPE S �+ PROPOSED CONMTRUCTION1bWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE4E3Y CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND R£RULATIONS 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 IM ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO DR BUB"CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' Ti A117 INUBT CA ]Lj., 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECP:�L� T39NO AT t20114684422, CO[�AJi/�.EfE DRAWING AT LOWER AREA PROVIDED. �,{l/1%t�'_ y//•j}^LjI_,1f,C�1a Slaned X A Tllfs PLOT PLAN(Drew to Beige)Beefe 'to 1. NAME"OF 6111FI TS 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. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUM OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. p.� EWT ECEit ...,. :... ....: Q�C ......1-1997-1- ...... .. SAN JOAQUIN COUNTY' PUl3yI ff LTHSERVICES,..,,,.., , .., ... _ DEPARTMENT USE ONLY Applleetlen Accepted BY Deto Ar"— f �L O—d ImPecllon BY eta Pump Inepeolleh D.++lnnrleti Tmnectbn BY bele_ (,•emmdHe: ACCOUNTING ONLY; Albs' FACT PE CODFA FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE PERMITISETVICE REOVEST NUMBER INVOICE 1 LF$ 1a(5kj-j b Pub.Health Serv.-Enviro.173(1/97)