FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT((' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVES ENVIRONMENTAL HEALTH DIVISION P.O. BOX M 804 EAST WEBER AVENUE, STOCKTON, CA WMI.388 (209) 468.2420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IAPPUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ATriplicate) INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN I JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVI610N_, JOB AODRE8810R APMN i4 U_ S�T-g11� [- e— CGy r �.j [L_�� I I 1 L (� OWNER'S NAME O� �� l4h ADDRESS `�S Z De,r A o !S Q��(X/� PHONE/1��+� CONTRACTOR r'BTW' or orADpRE6P � x 412 PHONE N f-"' 62j SUB CONTRACTOR ADDRESS LIC# PHONE+ TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLN (TYPE OF PUMPI 13 N.13NRapefr H.P. DEPTH RUMP BET FT. FIRr1L TER LEVEL p i 13OUT-0F-SERVICE WELL 11GEOPHYSICAL WELL s ORING 0 13 DEBTRCTION: - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ -DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE Of CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAO _ ❑OTH£R, GROUT SEAL INSTALLED BY GROUT BRAND NAME p ❑ MONITORING Q GROUT SEAL PUMPED: [3 Yee ON. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne S + APP"X.DEPTH �-__ LOCKING CHESTER BOXIBTOVE PIPE S PROPOSED CONSTRUCTIOWDPoWNG METHOD: MUD ROTARY AIR ROTARY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFiC FOR WHICH THIS PERMIT IS ISSUED,I$HALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'$COMPENSATION LAW$OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING 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 CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(200}48SJ42f. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIgnsd X Title Drda PLOT PLAN(Drew to Scala)Scale 'to 1, NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE 018POSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,HIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES 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. i S A•#1 ec�r � #' a DEPARTMENT USE ONLY fY/Jh Applicatlon Accepted 6y Dole Area J Grout Itnpeetlon By - Date Pump Inspection By pate Destruction Inspection By Date ' ` CommanW i'. t ACCOUNTING ONLY: AID* FACT -711 PE CODES FEE INFO AMOUNT REMITTED C NICASH RECEIVED BY DATE PEFIMIT/SERVICE REQUEST NUMBER INVOICE OLK) d 7