FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLiPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) 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$-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR.APNM CITY -PARCEL SIIE1APNr-�i� OWNER'S NAME ADDRESS ONE E O CONTRACTOR- � SJ 17� ,/, ,f�n�, __L�.Cy'7 ADDRESS�' LICNLT4&M PHONE'401s-- /7 SUB CONTRACTOR _ADDRESS LICJ' PHONE F TYPE OF WELLiPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALiATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J (TYPE OF PUMP) 13 New❑Repsir H.P. DEPTH PUMP SET FT. FIR WATER LEVEL O Q yy /� I ❑ OUT-OF-SFRvICE WELL ❑ GEOPHYSICAL WELL 10 14w-2 -N g DESTRUCTION; -4 6� I . !!NT______ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE_ TYPE OF CASING/STEELJPVC CIA.Of WELL CASING Q ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONIrORING GROUT SEAL PUMPED: ❑Yew ❑No CONCRETE PEDESTAL BY DRILLER:❑YM [IN. I APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE_ / a � PROPOSED CONSTRUCTION/DrtlWNG METHOD: MUD ROTARY_ AIR ROTARY AUGER `CABLE OTHER `�§ 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 ANO 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 THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERrIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK`OR WHICH THIS PERMIT IS ISSUED,I'MALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPEN&ATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 1209)14W-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Stoned X Title Date PLOT PLAN(Draw to Scale)Scale"to- A I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 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,S,j AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. -: u- ..-.-: -- - - a!-:_ l-.... . . ............ t . . + .... . . . . . . . .... . . . I � } _ DEPARTMENT tIBE ONLY I C9 / 6t Application Accepted B1Y� �� // Date ! G` r ,q[d[J'0,19 V 3 Grout Inspection BY Tom'��"'9 Datav�Pump Irupxtlon BY Date Destruction Inspection P.y Dole Comments: 412 r /� ACCOUNTING ONLY: ALO* FACP _OZ, PE CODES FEE INFO AMOUNT REMITTED H1- 1CA9H RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE X04 o.-S7f