Laserfiche WebLink
APPLICATION FOR WELLIPUMP PE' <br /> 1T <br /> JOAQUIN COUNTY PUBLIC HEAD SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., S fOCKTON, CA 95201.388 <br /> i <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> ICempists In TFipHmat®I <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 <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# City Parcel Size/APN# p <br /> Owner I s�Name �/ al AddressC�/ � "T 9 m'GGs ,l 5� Phone #157- <br /> . 7"' r <br /> Contractor Address d3 �� zpj Lic#�6' Phone # i5��®a <br /> tan S #°o �.�3.. <br /> Sub Contractor%n Address I ic# �" Phone <br /> TYPE OF WELL/PUMP: U NEN WELL [3 REPLACEMENT WELL U MONITORING WELL # [I OTHER <br /> STRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> [I INSTALLATION 13 WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> p New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PLMiP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS to <br /> [I INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 13 DOMESTIC/PRIVATE U GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] PUBLIC/MUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION � ,kP , <br /> [7 IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY'4 1: `�" GROUT BRAND NAME S <br /> u1�ITORiNG �, GROUT SEAL PUMPED: El Yes R"No CONCRETE PEDESTAL BY DRILLER: [3 Yes [3 No <br /> APPROX.OEPTN C LOCKING CHESTER BOX/STOVE PIPE <br /> 6016 <br /> PROPOSED CONSTRUCTION►ORILLING METHOD: MUD ROTARY" AIR ROTARY_ AUGER�BLE® OTHER® ` <br /> �1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: °I <br /> certify that in the performance of the work for which this permit is issued, I shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California.'$ Contractor's hiring or sub-contracting signature certifies the following: 1' I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSAT ION'Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURI Vi ADVANCE FOR JiLt REOUIREO INSPECTIONS AT(208)488.3423. Complete drawing at lower area provided. jo <br /> Signed Xt, Title tr ST Date <br /> PLOT PLAN (Draw to Scale) Scale ° to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> .) p <br /> A U J 2 . <br /> 'U81 IC r Eat ff i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By v Date 2 Area �' Lt <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By L �_ Date -?-d& 9fo Continents: AE+s�?��csw d d <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CGOES FEW AMOUNT REMITTED E lgCASN RECEIVED BY DATE PERMITiSERVICE REQUEST NUMBER INVOICE <br /> � .00 ® I Sb <br />