FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Film APPLICATION FOR WELLIPUMP PERMIT fWWSAN JOAQUIN COUNTY PUBLIC HEALTH SER1'�.; ENVIRONMENTAL HEALTH DIVISION PAYMENT RO, BOX 388, w4 EAST WEBER AVENUE, STOCKTON, CA 9MI RECEIVED (209) 468-3420 1619,06 SAN 1C,•'dillNG('lU tY NQN•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED PUBIC HrALTH SMACES (Campl$t$ In Triplint$) ENVIRONMENTAL MLALTH 01VI�SICN JOAQUIN CO N HERE EL MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION!S MADE IN COMPLIANCE WITH SAN JOADUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 6.3 AND THE STANDARDS OF SAN JOAQUIN CODU+NTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE88IOR APNs p/ a r /w AP L CRy y PARCEL SIZEIAPNI OWNER'S NAME G ADDRESS PHONE/ E CONTRACTOR �� r9�L � ADORRR��gggg$`�`S3 UC# PHONE A' SUB CONTRACTOR J 1 Se' + S ADDRESS { IK,j$�J,�fsD�E 0 n.44 y[L TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER T7 _ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! I (TYPE OF PIIMPt 13 Now 11Recalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p �-�// 13OUT-0F-SERVICEWELL 1:1 GEOPHYSICAL WELL S ❑ SOIL BORING t g LlE DESTRUCTION: I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D ❑ OOMESTM/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEL09—_ `a! DIA.OF WELL CASING ��N D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 7-1> r�1,1` — SPECIFICATION R ❑-•y1 IR ``RIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY 'Y 4�'�( GROUT BRAND NAME 1�� E clO ,% wrontiNG GROUT SEAL PUMPED: ❑ L!f s Ne CONCRETE PEDESTAL BY DRILLER: 'Tw ❑Ne S i APPROX.OFDTH LOCKING CHESTER BOXISTOVE PIPE g PROPOSED CONSTRUCTIONIDR(LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMSY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION$OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP"IIATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING 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 _ CALIFORIMAA,l THE CANT MUST 9,ALL�HOLVA IN ADVANCE FOR ALL REQUIRED INSPECTIONS ATt2t2j0S1 440-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED, r�� 510ned �� Title \ y� Ls-4- Date �II (J c PLOT PLAN(Draw to Saole)Saila—"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,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, 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. .. a ...... � - ......>....;......; .........<........... ... .. .. .....<.......... .. .. .. DEPARTMENT USE ONLY AppllratFen Accepted BY ``' Date r 4 1 T-..-- Area ` Grout Impeetlon By Dote Pump Inspection By Date bmtructlon Impecllon By Date Comments• ACCOUNTING ONLY: At DI FACt PE CODES FEE INFO AMOUNT REMITTED CHECKffCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE X02 22�. da