FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

':PPLICATION FOR WELL/PUMP PERMI' SAR JAQUIN COUNTY PUBLIC HEALTH SEK-CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complttt In TRipiiettt) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WR/1 SAN JOAOUIN COUNTY DEVELOPMENT TITLE.•CH'A-PTTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYPUBLIC HtE/ALTH SERVICCEES,ENVIRONMENTAL HEALTH DIVISMH. JOB ADDRESSOR fAP(NO/ 341 r(/fAdA !Q1 (' CRY_ j� ttPol G" PARCEL SIZEEIAAPN/ OWNEn'S NAME GQV(LOIN /G^I 7� LS FSS . LL r— ADDRESS P IC/� MWT)AJ�Z, CA- i�foNE 3��-5047 CONTM��--CT1�TOLR �/11��14LIL'/t��).h rb�24 I� /T ADDRESS '[ LIC• FHON(E0 I'm SiW.CGIR11IGiiB(i.f.-P'E1✓10&A 1L��I XO� 0N/A't. AODRE6S ��1��'ST- UCI P116�/►�ZO-�� - dt TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL E ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J ❑N—(J R.p.t, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL• SOIL BORING /� „ R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑OOMESTICt mvATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING O ❑P UBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R �❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E UY MOMTORING GROUT SEAL PUMPED:❑Yr ❑Ho CONCRETE PEDESTAL BY DRILLER:❑Yu ❑N. S APTO%.OE/RH 6 LOCKING CHESTER BOX/STOVE PIPE PROPO BED CONSTRUCTION! LUNO METHOD: MUD ROTARY AIR ROTARY AUGERCABtE OTHER ' v I HE9EBY CERTIFY THAT 1 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 JOAOUtH COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK fOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWIAR'PUCANT MUST C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120014"/`J�2].COMPLETE DRAWING AT LOWER AREA PROVIDED. % _TIII. �l' Q 1 1 D.I. gkc PLOT MN OD to So.l.l&,i -t. 1.NAMES OF STREEtS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. 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. \�(� DEPARTMENT USE ONLY /t1 APpSaNbn A..-td BF___1Lf' / DN. 1'IV 'RlT 1 Atu Or.ttt IrwpKtbn BY D.t. P—In.p..tbn BY 111 r D.t• brUtetlon In.n.etbtt BY D.t. C.nnd.: �1LlL�i7 0 11 . 1 ` ACCOUNTING ONLY: AID/ FAC! PE CODES FEE INFO AMOUNT REMITTED CHUEC{KKfICASH RECEIVED■Y DATE FEWIT/SEANCE REQUEST NUMBER INVOICE 1 rIIkolso Pub.Health Serv.-Envuo.173(1/97)