SITE INFORMATION AND CORRESPONDENCE_CASE 1

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT r N JOAQUIN COUNTY PUBLIC HEALTH SERVICd ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 L (209) 468.3420 ' F NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED { (Complete in Tripikate) f 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 TITLE,CHAPTER 9-1115.3�A/ND THE STANDARD$OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# (L/L� CITY�r6�.��_ PARCEL SIZE/APN# Q~ OWNER'S NAME ADDRESS GO/ VnT _S j,��}��/fp (UA PHONE: CONTRACTOR fI bsigGr' ,� ADDRESS I'Y /U 9W LIC# PHONE#G—W, DR ; 7 SUB CONTRACTOR N 7 ADESB 7 e ai uce G.57 PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL © MONITORING WELL# ❑ OTHER I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# d ❑New❑Repair H.P. DEPTH PUMP SET FT. (TYPE OF PUMP) FIRST WATER LEVEL Q 49 11ouTT-0FSERVICE WELL ❑ GEOPHYSICAL WELL# 0 SOIL BORING 3 �yf/�/ 1 49g DESTRUCTION: Rn� � INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA,OF WELL CASING D ❑ PVBUC/MUNtCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GRDUT BRAND NAME E ❑ MONTRORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S { APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S LPROPOSED CONSTRUCTION/OPoWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER r7 i I HEREBY CERTIFY THAT 1 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 1 THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES vi 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 COMPENSATION LAWS OF CALIFORNIA.1 THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQURE/D IINSPPEECTIOON&AT 12091468-3423 COMPLETE DRAWING AT LOWER AREA PROVIDED. % Signed x Title 7]�1~' Ui�.0jS .C�y� _ 1 , 4 v One G L PLOT PLAN(Draw to Staley Scate 'to a 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I 2. OUTUNE 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. .i --.............................:....�.:....-......-...:.... .. .. - -. .. .. ......... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. - .. .. .. .. .. .. .. .. :.. ...... . . .. ............. . .. .. .. :......:... . . .. ........... .. . ... . . sieeaoR .. _ . _ _ ..��. � -rr��•�a-.-r"a`-s-,�- - �:-+��iu.ry�r�aW 1'�F''iwr�.�� .................................. ....,..., -...--._ ZC - DEPARTMENT USE ONLY Jf, 40 Application Accepted By v`-'l O lqq Area � ,� Date ; Grout Inspection By Date Pump Inspection By Date Destruction Inspectio ,n ,,B.y Oate I Comments: J�t/ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED HEC !CA&H RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE !i rz do 7. Lw