FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT • FF/z JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FRDM DATE ISSUED ORIGINAL (CampMte in Tripfieats) APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNT`/FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORD DESCRIBED.THIS AP ATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPk)fNT TITTLE.CHAPTER 9-11155.33AAND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICV HEALTH SERVICES,ENVIRONMENTAL HEALTH DVISION il5ac JOB ADDRESSMR APNIv C.''ff�'L-/ �l /v -�/\��IJIt�,�/� CN-y S' y/�/G,_I� I�GJ-�✓l �/ PARCELSIZE�/J/A{re,-,C OWNER'S NAM /E� ///4L. L �.WE ADDRESS ILIA R�Y� /YJIOJCJ r'IreL( PIgNEI, { 2 • 1• � CONTRACTOR \' �✓Vy� ILL ADDRESS "a A," � `0. UC/ SPHONE t- aus J ��Le CONTRACTOR C-IP U VVl 6-APIL"✓G e�A ADDRESS g+ZW- al Ucs �l 2Zbf$ PHDNEs -$712- TYPE OF W IJJPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 1 � ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROss.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑ N.❑RepNr H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL p (TYPE OF PUMP ❑ OUT-0F6ERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOB.SONNG g ❑DESTRUCTION: INTENDED USE TYPE OF WELL N� CONSTRUCTION SPECIFICATIONS L� A ❑ INDUSTRIAL ,,❑.(OPS i�VOM IhPT Krl-f CIA.OF WELL EXCAVATION I I /I i I OIA.OF CONDUCTOR CASING O ClDOMESTIC? ATE LJ FSML6L PfACKISIZE 5410 TYPE OF CASINGMSTEEI� '�f VICL(LLIC' 40 CIA.OF WELL CASING D 5,V�allow C' Cl PVBUCIMUNICIPAL ❑DRIVEN DERH OF GROUT SEAL !LAPP� �T,� SPECIFICATION I ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY C- GROUT BRAND NAME Nif,, Y t'WI G°vL E ❑ MONITORING I GROUT SEAL PIMPED: Vr Ne CONCRETE PEDESTAL BY DRIL Ek- Y.. y❑,N. S APMOK.0E 14 SYv,IILJ�„ ZZ J IJCe-P . � LOCKING CHESTER SOXISTOVER 1YCt C MOMSE0 CONSTRUCTIONIDPoWNO METHOOT MUD NOTARY AIR ROTARY AUGER CABLE OTHER r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OPDINANC ,STATE LAWS,AND RULER AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEPPORJ#A E OF THE WoW FOR WHICH (HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORgA 'a COMFFNSATION LAWS OF CAUFORNIA.'* TT�HE�AP CAANNT MUST CALL 24 HOUIR IN ADVANCE FOR ALL REGUIRED IINNSSI tlG ICTIONS AT 12001 4Y2I. COMPETE DRAWINAT LOWER AKI1'.PR/MED. q shod xI FLOT PLAN ID,.w to G.I.I Sul. -Ie t, 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 9Y9WMS. 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADWSZOP ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,OW VEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING IL OmARTMENT USE ONLY / � Avvll<alen Ace«led By 1[/—�-•`4—_ _ }yts 7/ Mr Gaul Irnv«nen By 0•m •EjPRP In.P«tlen By �T OnS DrVVcllen I,wq�odan BY , _ D.I. ACCOUNTING ONLY: AID/ FACT PE COD" FEE INFO AMOUNT REMITTED CHECKSMASH RECDVED BY DATE PERMIT/SERVICE REGUEIT NLMSf11 INVOICE I