SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

y '3PLICATION FOR WELLIPUMP PERMIT SAN'tfdAQUIN COUNTY PUBLIC HEALTH SERVvIdES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete MI TripReBlel APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COLINTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITII SAN JOAGUINI COUNTY DEVELOPMENT TrrLE.CHAPTER 8-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBM HEALTH SERVICES,ENVRIONMENTAL HEALTH DIVISION. JOB ADDRESSOR API/ CITY PARCEL OWAPFIR OWNER'S NAME ADDRESS PHONE I CONTRACTOR ADDRESS LIC/ PHONE I RUN CONTRACTOR ADDRESS Lx# PHONE I TYPE OF WEU)PUMF. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALIATION ❑ WELL SYSTEM REPAIR ❑ CROBB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ./ (TYPE OF PUMP) ❑N.O Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ OU►-0E-SEINICE WELL ❑ GEOPHYSICAL WELL I ❑ 104 BORING a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO O ❑ DOME9TICtPR1VATE ❑GRAVEL PACKIRIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D ❑ PUBUCIMUNICIPAL ❑ORIGEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:❑Y. [IN. CONCRETE PEDESTAL BY DRILLErt❑Y. ❑No s APPROX.OEPTH LOCKMO CHEBTER ROXISTOVE PIPE s PROPOSFD CONSTRUCTION/DR[LLINO METHOD: MUD ROTARY AIR FIOTARY AUGER CABLE OTHER --- I HE9E9Y CERTIFY THAT 1 14AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 11EGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 GHALL NOT EMPLOY PERSONS SUBJECT TO WOM MAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S N"HO OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT M THE PERFORMANCE Of THE WORK FOR VVMICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOPWAAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MOST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPICTIONS AT(20`014401-2622. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sla—d X Title On. PLOT PLAN(Drew to S.MaI Seal• 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,1NCLUDINO COVERED AREAS SUCH Ae PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOINING PROPERTY. DEPARTMENT USE ONLY Application Aeeepted By Det Ares GmR lrnpeetlen By Dot. R1altp Inwaetlen By one beatmall n Inrpaetion By Dat. Cemmetxa• ACCOUNTING ONLY: AIDF FAC! PE CODES FEE INFO AMOUNT RUMTTED CHECKMASH RECEIVED■Y DATE PERNSTISIIPMCE RI[QUEST RUMSER INVOICE Pub.Heafih Serv.-Enviro,173(1/97)