FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

fl APPLICATION FOR WELLIPUMP PERMIT (IwoSAN JOADUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKMN, CA 95201.988 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; (Complete In TripReat&) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORT(OtSCR19EO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 2gA1jV /,, CITY I `_, s PARCEL SIZE/APN# QEt,`' OWNER'S NAME 4- A gg W�'Ml'(�� u—T7/S CONTRACTOR ADDRESS a�yy�� V' Licit PHONE#29e��Z��/ $US CONTRACTOR ADORESB`�Gt:7TJ � � ♦�, � TYPE QF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# _ J ❑New❑Repair H.P. DEPTH PUMP SET FT. F199T WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL If 'EVSOiL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSF A 13Z INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z __ DIA,OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASMOISTEELIPVC: DIA.OF WELL CASING p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �-i�] —_ SPECIFICATION i R 111RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM£ E MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑/JY. 13N* 5 PROPOSED CSO MI'MUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY IMO CHESTER S AUGER PIPE CABLE QT 1J W �7 a� 5 I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THFAPPYFANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 12MI 4M-342a. COMPLETE D NO AT LOWE.R AREA PROVIDED. Slpned X jPjj� -. TMe Date y• /� �� PLOT PLAN(Draw to Scale)Scala 'to I., 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE D1 IMM SYSTEM OR PROPOSED ' 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ' 2. 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. :.....:.....-.f.....:.......:.. ..t.. ...... .. /i/�IJ�e,�f! - ..... i �. DEPARTMENT USE ONLY Applloatlon Accepted By Det. tt l J t Arca�• rO' r Grout Inspection By pate Pump Inspection By Date Destruction Ins By i ♦ s- I /� Comments; _ Date (/V r l./ I ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITIIERVICE REQUEST NUMBER INVOICE 00-7,7tr