FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

`tii.dPPLICATION FOR WELLIPUMP PERMh+" 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 FROM DATE ISSUED (Complots IB TripReats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTll SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# t!ZT(tf r1 r r_� L l f� t '1-t!Y CITY �4 a PARCEL 91ZE�_ p2/�'- ()-•,Z I OWNER'S NAME IL, ti}c?i? .V/JerKt f-S r «w1C' ADDRESS -- c In PHONE#--& 7-•&,WC) r �zo IcL,. c- —1y,-'Vt,•.37 �S CONTRACTOR C r.un l..-1.�v .r A— t' Ic•+�._t�Y / %—C ADORE 98�jr��„� t� _.7 c UC/ PHONE R_� iL.LL-'f.+'Yi r RUB CONTRACTOR v ADDRESS C y'3- LIC1 4-44n 2 70 PHONE• , S--/t'>/y 0 4L,d TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 11Naw 1:1R.polr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE Of RUMP) �y{ �,�•�— ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I )A,1 8011 BORING (' q j A 1 g ❑DESTRUCTION: � INTENDED USE TYPE OF WELL CONSTRl1CT10N SP£CIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELMVC DIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 1 Q, L SPECIFICATION q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY "rA�a.t.t. GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [:IN. CONCRETE PEDESTAL BY DRILLER:❑Yr CIN* 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DIBLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 MMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 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 81.1"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT M THE PERFORMANCQF TTCANT MUST CALL 24THE WORR K FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T APPLICANT MUST GALL 24 HO IN DI/ANCE FOR ALL REQUIRED IJN�SM"ONS AT 1200)4084422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slprted X Tltio /H ��4'ty�.'u-::S i Oe,, 57,1;1li- Data PLOT N (Draw to Sa.Iel Saab to 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,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLB WrTNIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. F1 ' .. ;. ... ... I DEPAATMENT USE ONLY App"cotlon Aaeepted By/ ` .en Data A— By Inopeatlen By `A iAAAADotPimp In.pectlen By vote DMtrtrctlen tnopectlen By Dote Comment.• ACCOUNTINO ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �So ) a0 1A3) - OOzz-C1 Pub Health Serv.-Enviro.173(1/97)