FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

3� APPLICATION FOR WELL/PUMP PERMIT ��- �,. '�; E D/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES`' ENVIRONMENTAL HEALTH DIVISION 0-1 19 304 EAST WEBER AVENUE, STOCKTON, CA 952 � HEALTH(209) 468-3420P 'P �w ?�41 .. MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT r�R11/lGES Mamplata hr TrlpReatsl APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUfN COUNTY DEVELOPMENT TRLE.CHATTER 8-1116.3 AND THE STANDARDS OF aW JOAOUIM �IALT"tPARCEL OWNER'S NAME asSeI Ct 4N�_Q I"1'4M f ',-,N.s IS vh, ADDREse1 593 S. Am:st l`Iq 6a., K 1p Dtl 933 r PHIONEf--5-99- 41D5 CONTRACTOR F S S o l, F-hd i r 0 h m!4 t" ADDRESS 393 6 1 0¢115 p i g 6� ucr 6 83$6 5 PHONE I +T2-�1 s10 SUB CONTRACTOR 11�I� t'j S P r I m S�S x�Z - , ADDRE98_-_- - i LIC PHONE r TYPE OF WELL/PUMP, ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER ❑ INSTALLATION ❑ WELL eYBTEM REPAIR ❑ CnOGS.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r 1 ❑New❑Rep* H.P, DEPTH PUMP BET FT. FIRST WATER LEVEL D RYPE OF PUMPf U ��jj ❑ OT.OF.BERVICE WELL El WELLS BOIL BORING._7r_ V^!IV 0 b e- 0 ❑DESTRUCTION: 130�I'►��S INTENDED USE TYPE OF _ CONaTRUCTION SPECIFICAT10NA { L 11 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 4 I yI L DIA.OF CONDUCTOR CASINO A D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKMZE TYPE OF CASINOISTEEUPVC q C N DIA.OF WELL CASINO N A O ❑ MMJCAMUNICtPAL ❑DRIVEN DEPTH OF GROUT REAL 2 7 Nvir SPECIFICATION A R El GATONIAG ❑OTHER GROUT BEAL INSTALLED BY v-t ki I GROUT BRAND NAME witifG PM I E MONITORNG GROW BEAL PUMPED: ❑Yw 21H. CONCRETE PEDESTAL BY DRILLER:❑Yea ONe 5 APRROX,DEPTH 2S �'i`e LOCKING CHESTER BOXI9TOVE PIPE s PROPOSED CONBTRUCTONMWLWW METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OT14ERke�T'p YG ' p1 r�c�Pu sh, 1 HMOY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,BtATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOIMND:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIB PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOROMAR'a COMPEIISATtON LAWS OF CALIFOMA.- CONTRACTOR-6 HRINO OR SUB-CONTRACTINO SOHATURE CiTT WARS THE FOLLOWINO: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THM PEMSIT IS ISSUED-I$HALL EMPLOY PERSONS SUBJECT TO WOROOMAWS COMPENSATION LAWS OF CALIFORNIA.- TH^E APPLICANT ,MUST CALL 24 HOURa IN ADVANCE FORLL AREQUIRED IMSPWTONB AT ROSH 44114~27. COMPLETE DRAWING AT LDE ped OWER AREA PROVID. n sloX - T -` 6 1 TRh C o V1 sq +-Q`t Dot. '� I 9 .T' T'O S E P I1 Tk h M/f&-ELOT FUR ID.ew to 900001 Se.l. -to 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE DISPOSAL BYBYEM OR PROPO9EO 2. OUTLINE OF THE PROPERTY,GIVWM DIMENSIONS AND NORTH DIRECTION. EXPANSON OF SEWAGE DISPOSAL 9YBTEM9. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. STRICTURE",MLUD"COVERED AREAS SUCH A@ PATIO@,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIONG PROPERTY. .. :.....:......E... '.....:......y ....... .. .. ......... .. .. .. .. .. ErN R D.h G I [i~N.�..... lIt.0 tf. D..... DEPARTMENT USE ONLY /� 4 Applleetlen Aeeeptod BY�� N " -`" --- Date 01e.n ImpeetleR BY Dat. Pump fenpeetlen By bele be.Inwilen Inrpe Dan 9YDete in CeR"".: — IA yrst ., -- b ------ - A& ACCOUNTING ONLY: AtD/ FACS PE CODE& FEE INFO AMOUNT REMITTED CHECKIX:ASH REC9VED BY DATE raw TISERVICE REQUEBT NUMBER INVOICE - Pub Health Serv.-Emriro.173(1/97)