Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICjS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 95201.388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION I6 HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTR 1CITANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER S-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN' Hr e4s7- yg /A/6 /A� CITY .sno-erJA/ PARCEL SIZUAPJ' <br /> OWNER'S NAME� ADDRESS /7,0. $Ok b�D� .S91/ RHO NE'/S/0)$-/.1-.Q(i9t— <br /> CONTRACTOR �3,Cr7/EL —,Qy,T/✓ �,kL ApDREss 3/LH CccO G'9 Dty Licit 1ZOM RHONE#&/J)63/-/JW <br /> f� J <br /> SUB CONTRACTORI}Ry ADDRESS '/57-1 erWrA 1-4,1 gggl .CCN .f•11/2T— <br /> gHONEI �(i -f/f� <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPO.EXTRACTION WELL i J <br /> fTYPE OF PUMP) ❑New C3 Repair H.P. DEPTH PUMP SET ". FIRST WATER LEVEL p <br /> Com.. �❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL' ❑ SOIL BORING S <br /> x,ei A <br /> DESTRUCTION: <br /> INT—..0 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICIPIUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC DIA.OF WELL CASING D <br /> ❑ POBUCIMUNICIPAL ❑DRIVEN DEPTH OF GREW SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT REAL PUMPED: ❑Yes ON. CONCRETEPEDESTALBYDNLLFR:❑Y. [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOJUS'TOVE RT£ S <br /> PROPOSED CONSTRUCTIONIDRIWNO METHOD: MUD ROTARY AIR ROTARY AUGEfl CAME OTHER <br /> 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 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WONL FOO WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORMAAN'S COMPETISATNIN LAWS OF <br /> CAUFORNIA��THE AP®®®PILICC1A�NT MUST C�jALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 112209148/11// 23. COMPLETE DRAWING AT LOWER AREA PROVIDED.C <br /> SIPeM x +Ti-./J?J � ly-� Tine ._1GTSI /Q Oic/�O p.l. -/- //t <br /> ROT PLAN ID.le Seals)Beale •to HO <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PFIOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 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 WALICS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> r <br /> /3a <br /> I ti17 <br /> r jig <br /> 1 3 <br /> b ti /"!r O.. W.. <br /> d <br /> RHT'a <br /> AN <br /> Drso.Raysac' � <br /> Ss�Arvns <br /> ILL) N <br /> O <br /> DEPARTMENT USE ONLY <br /> APpliceUon Accepted BY Date I I I' 1 J A,.- <br /> Date Pomp Iropectlen By _.—_. _ Gee <br /> OmeLctlon URPecRicn BY Date <br /> Comment.: DyerhY Lll I^Au13 + Mw[I -Pywssoyv yt MWS +Ikbtula <br /> AQeouxnxG ONLY ao' FAC' <br /> PE COD" FEE INFO AMOUNT REMITTED CHECK'/CASH RECEIVED BY DATE PERAIMSE RVICE REQUEST NUMBER INVOICE <br /> 2 561 4•/4• 2 01215 <br />