Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVIV <br /> ENVIRONMENTAL HEALTH OIYISION <br /> P.O, BOK 3K 304 EAST WEBER AVENUE, STOCKTON. CA M01-3N <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Campists M TFipn ats) <br /> 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 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMSION, <br /> JOB ADDRESS/OR APW/ f�m0'✓ . �7-~ CITY 67VCCT��jJ'-II,...,.,r, PARCEL SIZEIAPNN <br /> OWNER'S NAME 1/LQ+./ L I ADORE66�.�,j �j¢/Q¢ PHONE! -S laI <br /> CONTRACTOR 44!!J[� �- /�r-t ,�.1�• ADDRESS.Q rJI1rJWc FD J02*j[17nt7- LICS PHONE 3J3 <br /> $UB CONTRACTOR ADDRESS LICJ PHONE f <br /> c <br /> 3 <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL <br /> -AV-f. ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ./ <br /> ❑New❑Rep.lr H-P. DEPTH PUMP SET FT. FIRST WATER LEVE[ O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING g-1 YyiceA.A-5"d~I� e <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 'b4/ _ DIA.OF CONDUCTOR CASINO -JA p <br /> 13OOMESTICIPRIVATE 13GRAVEL PACK/SIZZ TYPE OF CASIN016TEEf®,.�`c+reW[E•40 DIA.OF WELL CASING +J O <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT 6EAL 0+ SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER OROUT SEAL INSTALLED GROUT BRAND NAME E <br /> MONITORING I GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne S <br /> APPROX.DEPTH 1 O LOCKING CHESTER BOX/STOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTIONIMUJNO METHOD: MUD ROTARY AIR ROTARY AUGER i>C­ CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERM THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' TH T UST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1120111)4"4422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X TltlaF�1�EOLLX+IS 1 - Date <br /> to 0 <br /> PLOT PLAN(Drew to Scatel Scats 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE:OISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> - - . - .. <br /> !f! _ <br /> r 'DEPARTMENT USE ONLY <br /> . r <br /> Application Axepted By � 0■te__��,��3 Area �,���' <br /> Grout Ire ? � J -~ <br /> pection By .131 pate�1 " f Puma Iropectlen 8Y Date <br /> Damructlon Inapeatlen Sy <br /> Date <br /> COmmenta: <br /> ACCOUNTING ONLY: AIDN <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED BY DATE � <br /> PU M1T1513MCZ REQUEST NUMBER INVOICE � <br /> ­tv OL, 161 s DD��Z.f <br /> I <br />