Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> S OAQUIN COUNTY PUBLIC HEALTH SERVICES It <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, <br /> CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNB 2CCV/ I I^e4 c y FlILICA . CITY I aL=y PARCEL SIZE/APNI <br /> OWNER'SNAME ADDRESS /_ / PHONE C/70-7831 <br /> CONTRACTOR E ADDRESS Sly 17 E/1 Gh e/fT n* 11CN / PHONE N 2 21/0 <br /> SUBCONTRACTOR UP' ADDRESS �L AJC s�u4UC 1? PHONE,f <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑ OTHER <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL l ✓ <br /> ❑New❑Repel, H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O <br /> TYPE OF PUMP) / <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL X 601E BORING 4v� 1 B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IO t DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATIONI, AA-- R <br /> ❑ IRAIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME N ClJrT's'L E <br /> ❑ MONITORING GROUT SEAL PUMPED: 11 Yes Ne CONCRETE PEDESTAL BV DRILLER:&Vr ON.` S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTRUCTION/MLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY 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 <br /> REGU S OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> ICH RMIT ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIVING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> TH FOLLOWIN CERTIFY THAT IN THE PERFOR CE OF THE WOW FOR WHICM THIS PERMIT I6 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'i COMPFNBATION LAWS OF <br /> C MIA.' HE APPLICANT BT 2aLw 1 VANCE FOR ALL REOUNiED'IN/S/Py/K�fTO�N•i�AT Rzoal McJ833. COMRFTE DRAWING AT LOWEfl AREA ED3 9� <br /> Sip,d X / Title <br /> PLOT AN IDrsw to Geslel Sala 'to <br /> 1. NAMES OF STREETS OR ROADS N R TO OR BOUNDING THE RWOpERTY. d. LOCATION OF HOUSE SEWAGE DISPOSAL eVeTEM OR PiROPO3ED <br /> Z. OUTLINE OF THE PROPERTY.GIVI IMENSION6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPO8AL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... <br /> ... . <br /> ,R (V��� DEPARTMENT USE ONLY <br /> Application Accepted BY �1 ✓' \ ✓vv" `7� Det. 4 ` r Ara <br /> Grout Impaction By N- Gets Pvmp Inspection 8y Date <br /> Destruction Inspecti By /1� I I Dets <br /> Comments: <br /> ACCOUNTING ONLY: AIDM FALX <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKY/CASH RECEIVED BY DATF PERMIT/SERVICE REQUEST NUNIBEIR INVOICE <br /> 7�1-C' l � a0 <br />