FIELD DOCUMENTS_1998-2000 - Laserfiche WebLink

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4PPLICATION FOR WELL/PUMP PERMIT SA<•AQUIN COUNTY PUBLIC HEALTH SEES S _ ENVIRONMENTAL HEALTH DIVISION ll1 304 EAST WEBER AVENUE, STOCKTON, CA 95202 002— (209) 468-3420 I NON-REFUNDABEE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED /^� TV, IONST abi,UC In ITmn IN P1 R I G0 j RA APPLICATION IB NEP/BY MADE TO THE SAN JOAQUIN COUNTY FOR-A PERMIT TO CONSTRUCT AND/OR INSTALL THE WDIK DESCRIBED.TIIIR ICTTpI�I�ppJ, E Wfill SAN JOAQUIN COUNTY DEVELOPMENT/THIS CHAPTER 97-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH RA JOB ADDRESS/OB APNI (- j / V E to CITY &Oa 717-1 PARCEL BIZUAPJI 0 �-y1-a .�e l'.ug Dry Clownifvq De e.�ua-n s CSDrTDs /y0O Pa1✓e)I Sy,-ee f, /,R F7,- OWNER'S NAME /el Dn Old T 'R L / ' E F CL P1' e_Ew+ p L',¢ �/y(,0$ 8.77 PHONE I S/0 -6s;-1/�QQ f CONTRACTOR ADDRESS LICIT PHONE/ /�''qq / 6 OD a as104116r,470-a-0-1 o4e) OQd SUB CONTRACTORJdIE e-KS lri��'.vw c�r,cC 211m� (IO ADORE68�p1-aa t'fe�e1 C'K}715173 UCCI /7768// PHONE/ 707-8.73.3/: TYPE OF WELUPUMP: IG] HEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ® OTHER GIJu L'•XTr- �r.)LjQ, ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECCT REPAIR ❑ VAPOR EXTRACTION WELL U AJ0(4Q.S Nev.•❑R«.II N.P. DEPTH PIMP BET 80 FT. FIRST WATER LEVEL O ITYPE OF PIMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION ��nn Pi/C OF CONDUCTOR CASINO /Aft/} D ❑ DOMESTICIPRIVATE ®GRAVEL PACKAHZE .-,L,# //p TYPE OF CASING/STEELJPVC M 80 P//C. DIA.OF WELL CASINO ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .7o/ SPECIFICATION B ❑ IRPoOATNINIAO �I❑I OTHER GROW UAL INSTALLED BY 1)r J Ike r GROUT BRAND NAME Uee n YN PN RIE 0MONITONGI�j(�r0.6)`I'A� GROUT SEAL PUMPED: ®Y.. ❑N. CONCRETEPEDESTALBYDRILLER:®Yr (IN. 5 APPROX.DEPTH 90, LOCKING CHESTER BOX/STOVE PPE )LES 5 PROPOSED CONSTRUCTi IUDMILUNO METHOD: MUD POTARY _AIR ROTARY AUGER �"' CA—BLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATTON AND THAT THEWORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR UCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA./T/11�'APPLICANT MUST CALL 31 ULE IN ADVANCE FOR ALL REQUIRED(IINSPECTIMNr1SSAT IfOel 460J 123. COMPLETE DRAWING AT LOWER AREA PROVIDED. SI.—I X ( �jY� TI1Ie �]/ /"'r-O 1 P r Maj 01 P r— D.tv POT PAN ID'.w Ie Sew.)Rc.la 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OB BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WT RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROP) Rry, I " Hp 17fto c�► e �. FEB 23 19 8: SAN JOAQUIN TH O ENVIHONMEN AaLHEALTHDIVSIOp DEPARTMENT USE ONLY q AVPIle.Oen Ave«led BY 1-'- 3—LIf-j Ara. 011 1 IneP«Oen BY D.ta Pump Imo«Oen BY D.I.— Go. ACCOUNTING ONLY: AID/ FACT PE CODES FEE INTO AMOUNT REMITTED CHECKIMABN RECEIVED BY DATE PEIPAIT/SERVICE MODEST NUMBER INVOICE 290 Qu3 S n 2- 23 ©psi Pub.Health Sew.-Enviro.173(1/97)