Laserfiche WebLink
APPLICATION-OR WELLIpUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 38Q 304 BAST 1NEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 469.3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TripOcatel <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /�f <br /> JOB ADDRESS/OR APNNCire ro <br /> P <br /> J,, PARCEL SIZElAPNI <br /> OWNER'S NAME V\ S ,t� ADDRESS Po, (0 y. 'aa� <br /> PHONE/ �2 Z9_ ..��' <br /> CONTMCTORI. �'c'y,y AbbMa /� o Q1(� F jet PHONE I '''�'{'� O<lUI <br /> SVS CONTRACTOR W [ ADDRESS :LJ\ � Al I%*LIC(If 7O P'HONE/ -J[ �7 r� <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MDNnORING WELL s ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL,p <br /> (TYPE OF PUMPI <br /> C1 Now 11R*pelr H,P, DEPTH PUMP SET Fr, FIRST WATER LEVEL <br /> O <br /> ❑ DVT-OF-.SERVICE WELL ❑ GEOPHYSICAL WELL♦ © SOIL BORING S <br /> DESTRUCTION: "► <br /> INTENDED UbE TYPE OF WELL CON&iRUCT10H&PECIFiCATION& <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASfNO p <br /> ❑ DOMEBTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STFELIPVC DIA.OF WELL CASINO D <br /> © PUBLIC/MUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATtONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: 13 Yee ❑No CONCRETE PEDESTAL BY DRILLER;❑Yw []Me S <br /> APPROX.DEPTH LOCKING CHESTER 15OXMOVE PIPE. S <br /> PROPOSED CON&TRUCTIONR'IISLLING METHOD; MUD ROTARY AIR ROTARY AUCIri CABLE OTHER <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPUCATK)N AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AHD <br /> RFOULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORX FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.• CONTgACTOR'S HIRING OR SUB-CONTRACTIND SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEA&ATION LAWS OF <br /> CSIAU a0PiN1A,• THE App41CT1NT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS 1112041409-2422.� C��PLETE DRAWING�AT/LO-WEN AREA PROVIDED. <br /> X. [►, / 'f1 - Ll 'lJ 1`r-y- �r bete <br /> PLOT PLAN ibrow to Sade)Sed* 'to <br /> T. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PMPERtY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNC5 AND LOCATION OF ALL EXISTMO AND PROPOaEb S. LOCATION OF WELLS WITHIN RACW@ OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MJCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT VSE ONLY _ <br /> Appllcetl*n Accepted By <br /> Del***�?�rw <br /> OretA InoP*ttlon By *f— <br /> Date Pump 1nsp-tion Sy <br /> Dote <br /> De.tnrclhn ImPsellen B <br /> Dole <br /> Cernmenu; =a�e� <br /> ACCOUNTING ONLY; Arno FAC& <br /> FEE INTO AMOUNT REMITTED CHECKItCASH RECkTVED SY DATE PERMITISERVICE REGUE&T NUMBM INVOICE <br /> F. I <br /> mvp <br /> Pub.Heafth Serv.-Enviro.173(3196) <br />