Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT• <br /> SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION n <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.988 IVY/ <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CamplatE In Typliub) <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,CHAPTER 9-11111 EE.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB ADDRE68IOR APNi�LDC•Z �^•L.� dK$,, / }-,C, J 1 CITY <br /> FFF12ALcv PARCEL e1ZElAPNI <br /> �SyO <br /> OWNER'S NAME/rJ ✓r �P ,✓ ADDRESS�O GnX ��. J,F/y„/ r jq PHONE f r RAZ-6930 <br /> CONTRACTOR /� ' Sin - p /N ADDRESS Lov,SES[y�w71�/T. _ UCI L3G387 PHONE Y4Q b-9875 <br /> SUB CONTRACTOR ADDRESS UCI RHONE f <br /> TYPE OF WELL/PUMP: ❑ NEW WELL Cl REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS6-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> R VPE OF PUMP) <br /> 1:1N.13eo <br /> R .Ir H.P. DEPTH PUMP 6ET_FT. FIRST WATER LEVEL O <br /> ^� <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I .� SOIL BORINGS 1p I LJPT R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ag <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WEltr o{kCWAiHGM Z'S~ 6!> DIA.Cf•CB}eDyCTpRrRBINp NA <br /> D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYR OF CASING/STEEVPVC AJ A DIA,OF WELL CASING ti A <br /> ❑ RISUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Sv//GJffhCp SPECIFICATION NA R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F, <br /> ❑ MONITORING GROUT SEAL MMPEO: ❑Ya [IN. CONCRETE PEDESTAL By DRILLER:❑Va ip <br /> APPROK DEPTH LOCKING CHESTER SOX/8TOW RP <br /> MOPOSED CONSTNUCTION/DRIWNQ 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 BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES A <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THEWORIC TOR WHI <br /> THIS PERMIT 18 ISSUED,16HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIF> <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT ib ISSUED.I SHALL EMKOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS <br /> CAUFORNIA.' THE CA MUST CALL 24 ADVANCE FOR ALL REQUIRED HNIR E MNS/AT 120S14SSJAI2. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> sl'�X Tltl. � (_Y-+c_oi_.cr Do. �Zo-fsy <br /> ROT RAN ID'.w 1.60.1.1 6u1. Re <br /> 1. NAMES OF STRE 8 O A S NEAREST TO BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED <br /> 2. OUTLINE OF THE PRORRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. `v <br /> 3. DIMENSIONED OUTUNF6 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> Appllwtl.n AeegteE By <br /> GreN Impgtlen By D.t. Pump Ivpepllen By D.te <br />' DaUVclien Irgpectlen BY <br /> 61 <br /> C.mmem.:�/ Dae <br /> v <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FFF INFO MOUNT REMITTED CHECKI/CASH RECEIVED By DATE PERMITISDHVICE REQUEST NUMBER INVOICE <br />