FIELD DOCUMENTS_1998-2000 - Laserfiche WebLink

Home Browse Search

SJVAPPLICATION FOR WELL/PUMP PER OAOUIN COUNTY PUBLIC HEALTH SERICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in TrIpReStel APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Joe ADOREeeroR APNI 376 Lincoln Center ctrY Stockton PARCEL slzE/AIN1097-41-46 S TTLI17 DRY E s 190 owe r. OWNEAV NAMEC O Donald T Bradshaw, Lev Lne-Fricke-Recon AM g�mer7v Llle, C 941608-1827 PHONE1510-652-4500 CONTRACTOR ADDRESS LIC/ PHONE I SUBCONTRACTOR Precision Sampling 47 Louise-St ADDnPsm San Rafael, CA 94901 (ICI(; 7 6387 PIONEk15-456-9875 TYPE OF WELLIPUMP• ❑ NEW WELL ❑ REPACEMENT WELL ❑ MONITORING WELL I— 11 OTHER 11INSTALLATION 11WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J (TYPE OF PIMP( 11 N.❑11".1, H.P. DEPTH PIMP BET_". FIRST WATER LEVEL O yy��II 11 OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL E A,q BOIL BORING g ❑DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL El OPEN BOTTOM DIA.OF WELL EXCAVATION 6-inch DIA.OF CONDUCTOR CASINO n/a O ❑ DOMESTIC/PRIVATE ❑GRAM PACK/SDE TYPE OF CASINO/STEELJPVB n/a DIA.OF WELL CASINO nIa O ❑ PIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL n/a SPECIFICATION cement-bentonite R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY n/a GROW BRAND NAME n/a E ❑ MONITORING OROVI6EAL PIMPED:AA Ys CIN. CONCRETEPEDESTALBYDRILLER:❑Yr [IN—. 5 APPROX.DEPTH mnitinlp horinVs 5-65 ft bgs LOCKING CHESTER BOX/BTOVE PPE S PROPOSED CONSTRUCTIONImtlLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEfty_d, 1 i r P ch 1 HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE"We,AND RULES AND REGULATIONS OF THE BAN 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 IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-COMRACTING SIGNATURE CERTIFIES THE FOLLOWING: .I CFGTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB IBSUED.1 SHALL EMPLOY ARSONS SUBJECT TO WORKMAM'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL A HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT POB(44419/22. COMPLETE OMWING AT LOWER AREA PROVIDED. qwe xe, , 1 - �O2 TRI. Site Project Manager D,le AOT PIAN IO.xy to Boole)Soelo •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR PROMBED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWADE DISPOSAL SVRTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. 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. n 7_/ Igll9 a ® �Q Iff E i `� • v 6YIN 1, ^ei O h e O OF �+ Cto a �•- D ON i Lf H u. rte w E`0 J f H lI' I Z l .ss F/ N-lT E2'6 S m 0 S �l f, � y� o \ Py/ - a•S 01. e> %a Z r DEPARTMENT USE ONLY Appllpolbn Amepled PY pole l r 1 V Ar" v 4 Oreut Impembn BY Dote Pmp Improtlen BY Det. Ombmeen Imp (len By �1�11L[/ Oota ACCOUNTING ONLY: AIDIF FACT PE CODES FEEINFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PERMITISFRVICE REQUEST NUMBER INVOICE 6'2b 5 Pub.Health Sere.-Enviro.173(1/97)