FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

PLICATION FOR WELL/PUMP PERM14 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FADN DATE ISSUED ICBmpkts In Tripe kst.l APRJCATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS AP ATION le MACE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRIS.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVBIONMENTAL HEALTH OMe10/N�. Jae AOOMSSIOR ARMS ^�y1 L I/;,.('q-A/M �]�.t y � cn/ S CT. 1 InJ .}, vAROEL SIZEIAPNg 13('/ -3 L OWNER'S NAME � �1`-'ry^' R1-�LNwk4'O�jP.a.� I `�.L/^UA. gB (d L ( O1y. SI uGO�,pGNEI `S ZOZ. CONTRACTOR P2ec i.z la l� ARSB Ce 1-15U LTA nT-C ADDRESS 6 120 KOLL GtR. Pkv Le-ASAr'M+NE I�I�-Z�BO TYPE OF WELLPUMP; ❑ NEW WELL ❑ PEPIAC£MMT WELL ❑ momromNG WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPOBSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J El •e H—❑Rrr M.P. DEPTH NMP SET—FT. FIRST WATER LEVEL G IT"OF NMP ^ ,R ❑ OVi-0FBERVIOE WELL 11 GEOPHYSICAL WELL I � SOIL BORING 12 L .L g �G,f(�I 11 DESTRUCTION: I '��/ �(�7 to QIQQ,Q SL4 [J V-A fil t&/N-�N^tiTr J INTENDED UEfi TYPE Of WELL!1 CONSTRUCTION SPKIFICATIONA A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA Of WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMEBTOA'RIVATE ❑GRAVEL PACK/SIZE TYPE Of CASINGATEELNVC DIA.Of WELL CASING D ❑ Fusuic MUNICRAL ❑DRIVEN DEPTH OF GROUT SEAL SRCIFICATION Al ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME g ❑ MONITORING GP.OUT SEAL PUMPED: ❑Ye• ❑Ns CONCRETE PEDESTAL BV DRILLER:Ely. ❑Ne S APPROX.DGgA LOCKING CHESTER BOK/STOVE PPE S PROPOSED CONSTRUCTICNANOWNG METHOD: MUO ROTARY AIR ROTARY AUGER CABLE OTHER t HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON(WILL Be DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. ROME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEFTOBMANCE OF THE WOR(FOR WHICH THAI PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOW&- CONTRACTOR'S HIRING OR M"ONTRACTINO SIGNATURE C£RHFI£e THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOROAAN'S COMPENSATION LAWS OF CALIFORNIA' THE APPUC NT WT CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSP��EC-TIONS AT LZINA 4SSJ422. COMFI.EE,T,E DRAWING AT LOWER AREA PROVIDED. Howe X W.1 L lS /I/�r�p�, _D.I. Z 11 Z not Pun BH...I.serol Eea. 'iP —� U�F- I. NAMES OF STREETS OR ROADS NEAREST TO OR BO RIDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPDPOSED 2. OUTLINE OF THE PROPERTY.GINNG DIMENSIONS AND NORTH DIRECTION. "PANSION OF SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTAIN RADIUS OF ONE HUNOMD FIFTY R. STAMTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Da TMENr USE ONLY APPEe•tbn Ae ld 0Y 0•b Mr GmM IwPwem Br DMS PRP 1m —q.n BY OMa D'wbwtbn Imemfbn 0Y 10ra Cemmmt•: ACCOUNTING ONLY: MDP FACS PE Conn FEE INFO AMOUNT REMITTED CHECXRICASM MEWED BY DATE PERMITAUDIVICE REQUEST MUMMER INVOICE .17 G b` .0 0 �� 6 f - 3 Pub.Health Sew.-E.mnro.173(1/97)