FIELD DOCUMENTS_CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 SOX 368, 446 N. SAN JOAOUIN ST., STOCKTON, CA 86201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CampMt6 in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT T�ITLF-CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. SMJOB ADOR£SSlOR APTf# KOCACI�TY7 PARCEL SiZEIAPNI - OWNER'S NAME V ADDRESS 1 . Q PHONE I Z CONTRACTOR �,,l` • ADDRE �1 CI LZ PHONE SUB CONTRACTOR ADDRESS LIC# PHONE I TYPE OF WELLMJMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER ' onLtJ.Qa ku)�r ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXT CT ION WELL# 13 u.13NRFT eps, H.A. DEPTH PUMP SFT. FIRST WATER LEVEL 04 y _ p ITYPE OF PUMP) . ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL GON6TRUCTION&pECIRQATION& A ❑ INDUSTRIAL El�OOPEN BOTTOM DIA.Of WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTICIPRIVATE G?GRAVEL PACKlSQE Z I Z- TYPE OF CASING/STEEUPVC OSA.OF WELL CASING rrG D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �•-•f q � M ❑�IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F LSA ONITORING pp GROUT SELL PUMPED: ❑Y. ❑No , CONCffTEPE�DE{�Sj'�f-AL 8Y D LLER:❑Ym Na S APPROX.DEPTH L� LACKING CHESTER BOX/STOVE RPE I V(,(_4UY't . 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY - - AIR ROTARY AUGER CABLE OTHER I HE9MSY 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 IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIENZATION LAWS OF CALIFORNIA.' THE APPU T T C 24 HOURS IN ADVANCE FOR ALL REQUWM INSPECTIONS AT[2091468-M423. COMPLETE DRAWING AT LOWER AREA PROVIDED. r SEgned XQt(j SS raw Aj- C. Tltla r0 J Date ` V { PLO m to Scale)Scow 'to 1. NAMES OF STREE"OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GMNG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO 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. DEPARTMENT USE ONLY 's€ Application Accepted By Date i ( ' Arae ` Grant Inspection By t Date 1J P e p Inepmdcn By i Data Destruction Inspection 8y cz Rete Comments: - ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISfRVICE REQUEST NUMBERINVOICE On a.