FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201 .388 (209) 468.3420 NDN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, ACHAPTER �9-1J11�5� ,31AND DTTHE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR A♦FRNIF f(010 /VV_1• , VI�^ C'/�'�AN SI ' �� CT' _ [S'�k L, �t'/1"_ '-� I,, PARCEL SIZE/APN# OWNER'S NAME /Af% , ` 1Za,\-4wLQ✓LLL F V. ,rwR.yr ADDRESS 38LO TyV ir�' ^1" v\ ./A%kkL AoI;ye 1PHONE # Wz p31 (oO CONTRACTOR S1 Ai4`%^ �A` - CL,�1/�E Ls54 � {1-' ADDRESS t ?. tO � v B+ P`A1 LS 4r, LIC# ' L43bG ` RHONE #SI'��T�l ' Z�ZI.�ZL SUBCONTRACTOR �/ � LIy V '� V �� L✓lQ �./ ADDREGBP C- gdY Si ILEO V1Sf� UI PHONE It • J�` ` TYPE OF WEWPUMP: NEW WELL ❑ REPLACEMENT WELL R MONRORING WELL #3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAMPIEXTRACTIONVJELL # ✓ ❑ Naw ❑ Repair H.P. DEPTH RUMP SET_IT. FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-OFSERVICE WELL ❑ GEORHVSICAL WELL # LaL SOIL BORING � B ❑ DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ] 1, ry A 11INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION ./�1 DIA. OF CONDUCTOR CASING 1• O ❑ DOMESTIC/PHIVATE ❑ GRAVEL PACK/SITE TYPE OF CASING/STEELIPVC 'YVL/ DIA. OF WELL CASIINGy_ Zr, I O ❑ RUBLICIMUNICIPAL 1:1 DRIVEN DEPTH OF GROAT SEAL 231 SPECIFICATION Sck� 4f�0 VC, R ❑ RIGATION/AG lV OTHER GROUT SEAL INSTAL I BY TYaW11 e, GROIUT BRAND NAME N2-LL I Ce1h.EAn E MONITORING �7 GROUT SEAL PUMPED: pU Vs ❑ Ne CONCRETE PEDESTAL BY DRILLF11: ❑ Yep ❑Ha S APPROX. DEPTH LK ['C e { LOCKING CCHEEyTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONJmSWNG METHOD: MUD ROTARY AIq IIOTAgV ! ' AUGER CABLE OTHER 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 REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'l CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUPORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12y/OB) 44834M. COMPLETE DRAVBNG AT LOWER AREA PROVIDED. (y MarrelX � IMMe Lb PE. Title PLOT PLAN Mre to Gods) Scale ' to 1 . NAMES OF STMErS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PPOPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, NUMBER V / - 10 I —Al f>7 Fri e HUNTER 'n m g Z Ur $ o m z F j- a 6 J C n i0 ( r z yTP z x lC i1 m m 3 A I 'iRa wo F" fin 2 ap n � oz T j ' x A n o s $ = a = R In x A : . _ O m o i m In Xo Z A Z A M ii a 6 x < S nMK y ; r a y 0 a> rOv My 4 e A u z n m n — — — — — — — si 3 i DEPARTMENT USE ONLY Application Accepted By 1' Date YV - / / Arae Grout Inspectlon By Data Pump Inspection By Date Drtructian Inspection By Des Comment.: �¢e �bs /£t1D Corr¢SporiceL(R (a GomvkG � fS 8v111—c �ro�oKQlli� ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO AMOUNTREMITTED CHECK#/CASH RKEVEDBY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE D � hLe I VI b 2AL 35