FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMI~ SAN JOAQUIN COUNTY PUBLIC HEALTH SEhwdES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9MI X88 {209] 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICempwtt In Tripliate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY//PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. J08 ADDRESBIOR A�P�7N/R� r r 1r C. UU I, 1�y�� PARCEL SIZFJAPNI OWNER'S NAME - +L V1A� ADDRESS St— y�n ��]] �n/��1 rW0�DO`�+/� PHONE I I CONTRACTOR pp Q , ADDRESS--l�a�--1--�I��S �-I-�� LL-T\ LIC/ PHONE# lip 21� OUR CONTRACTOR 1. ` ADDRESS M51 I111)IC 4 WQ�T LK:4 PHONE!� S-�-� TYPE OF WEU&UMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINQ WELL 4 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Naw❑Rapalt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING, g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN ROT-TOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING Q ❑ DOMESTK:IPRVATE ❑GRAVEL PACKISRE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yse ❑ is S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRLICTIONIDRILUNG METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T14I8 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S 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 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN't COMPENSATION LAWS OF CALIFO ' THE APPLICANT MUST CALL 4 HOURS IN ADVANCE FOR ALL REOUME]INSPECTION*AT 12051 4p-2423.CCOMPLETTEE DRAWING AT LOWER AREA PROVIDED. �] r� Signed X Tltla 1 I 1-1 � �'s 4"'V� 1 oats_�!-q70 PLOT PLAN 1Draw to Scalel Scale "to 1. NAMES OF STREETS OR ROADS AREST TO OR SOUNDING 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 OUTLINE.$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, 1 DEPARTMENT USE ONLY Application Accepted 8 L DMe A ✓ Arco G+out Inspection BY Date Pump Inspection By pate Destruction Inspection By Data Comments ACCOUNTING ONLY: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH RECEIVED BY DATE PEIIYNTISERVI E hEQUEST NUMBER INVOICE r fOU "130