FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

PPLICATION FOR WELL/PUMP PER SAWOAQUIN COUNTY PUBLIC HEALTH SACES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompl@tE In TFIpRutel APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC.HEALTH BEICEB,ENVIRONMENTAL HEALTH DIVIBION. � JOB ADDRESS/OR APN/ 023- 150- 14 CITY �"ALV 1 S PARCEL SIZEJAPN/ OWNEA'9 NAME ML L17 ' 57 -��--�11 ADORERS �K'D rv"N PHONE/ (2 CONTRACTOR OLIVIAL Cuyoj eOAI Wt2 '24e ST pY 5C# �4 197 (s "U^^�� ADORERS_ '_^�% i S /OO LIC/ ATONE I I SUBCONTRACTOR PITUIEir- mLi-44G CO PO. X 503L7 Z [i•I$ oY ADDRESS FAt o AI_-hA , � . LJC/��P.J�w0�Bc- ; PMONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ OTIIER P•�w�•oc�•-1� (2-25) ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑N.❑R. .I, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O ITYPE OF RUMP) ❑ ❑ OUT-OF-SERVICE WELL GEOPHYSICAL WELL/ �vyr❑ SryO�IVLtaBORING Cn�,�r�y,n L.� B DESTRUCTION: P'W4A -w ®s- N VrAA-I.-" IN1 cAFMA- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 7 J/ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S /8 DIA.OF CONDUCTOR CASING 0 ❑ DOMESTICRWIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELJPVC wL GIA.OF WELL CASING I R/ D ❑ PUBUCIMUUT NICIPAI ,❑Id(DRIVEN DEPTH OF GROW SEAL N YD/ SKCIFICATION , 8 PI�TwQ ZI SRgL n ❑ IRRIGATION/AA OTHER (PIeZaVaZag� GROW SEAL INSTALLED BY oIT� GROUT BRAND NAME E MONITORING GROUT SEAL Rgq1t UMMO: ICL Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Ys ❑N. 5 APPROX.DEPTHa0 LOCKING CHEATER BOX/STOVE ST/PIff S PROPOSED CONSTRUCTIONROULUNG METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER ac' FM2 A DE744LEp DmsR4PROtA aF PI sXO VA1Yr4 llAmwtT1--"-Aw— X-� Qavrer+aK w&- pcywae lok\ MAA 1 HE-TRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,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 PERroRMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SMALL N PLOY PERSONS SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S MINING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN ERTIFY 7111AT I"PERFOSMANCE OF THE WORK FOR NMICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA TH AP CANMUST A fA MOWS IN ADVANCE FOR ALL REOURM INSPECTIONS AT 130S14SSAABB. COMPLETE ORAWING AT LOWER AREA PROVIDED. @lisw X THS. STAF7= '16MPAlEER D.I._ +A-s. 97 PLOT MN In'.I.Soo.)Bv.le •to1. NAMFB OF STREETS OR D9 NEAREST T OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PNOro BED Z. OUTLINE OF THE PROPERTY,GIVING GIME IONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ff. STRUCTURES,,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �M1, Ld7cA WQI OF' PJ��S+�"/ ��• 4'Li•.O �L.^ 2lr ^— $R,6"w— .7- '.. APT7�1G7'f�D -W NII��CPLHrtATIOAI MI�K- A-�• - - '.