Laserfiche WebLink
AT`F.v �rr� <br /> .,,•rk.a,,,i APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE a L C, o s' -a3; <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 0 <br /> (209) 468.3420 3 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 9-11/11 5..3 AND THE S1HN��OF SANJJOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> r. <br /> JOB ADDRESS/OR APN#' S,t xe �n'rA!/ h _ ��Or�l k CITY 4ofl! 44. J s'j-Y o PARCEL SIZE/APN+I S 3 <br /> �G tt/✓9y O{� —f4K* 'IG f1 Q91AI /f/© // Al lay S;�c/PHONE« °� 1 08TlTq <br /> OWNER'S NAME �+ ADDRESS ✓✓ <br /> Jy a p (.1_h f1 ror.0 1/.n 3 ov f.T /.1�s 1/."l i(/K /}✓t .f 0 v <br /> CONTRACTOR __..T/!�t� ��(-og-�r///L 6 Cbl� t!�M fel i;PI��ADDRESS J.L I I 0 r .:-' ! LIC* PHONE N ` /f" —/O rr <br /> SUBCONTRACTOR AHA r!' � 1) r "��'�• �fFv�'hR 5P ;tllgT <br /> Al �, i��I.'✓��- ADDRESS f�fyo Y.f w �=. ��ye.2rS LIC* /g /PHONE* o O <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* 161 OTHER �� d'r T.+(�J AAs s//•.S <br /> A ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL*, J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> 1TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION <br /> SPECIFICATIONS ` A <br /> DIA.OF CONDUCTOR <br /> 1v A <br /> ❑ (DOMESTIC/PRIVATE GRAVE LPACK/SIZE / TYPE OF CASING/STEEL/PVC ` f! DIA.OF WELL CAS NGCASINS D <br /> 1! D <br /> ❑ PUBLIC/ MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL NP pit P S SPECIFICATION PY C SC'fd R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY 7A 0 M Aleh _f)'014P /114P GROUT BRAND NAME�" 7 C p+O i r JPS E <br /> ❑ MONITORING AZS' r GROUT SEAL PUMPED: ❑Ys ANo CONCRETE PEDESTAL BY DRILLFR:❑Yea WN. S <br /> APPROX.DEPTH A j �A R✓Q T OY-r LOCKING CHESTER BOX/STOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER,CABLE OTHER <br /> 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 <br /> 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 <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> 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 <br /> CALIFORNIA." THE <br /> /APPLICANT MUST CALL <br /> 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 1209)468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. , <br /> /.f^'I✓y°..`_ lf� ",C1/ `T!K Title _ _ rb ✓'�f_T l W t h A Po-, Date 61 a, 3/q V <br /> Signed X •- <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 PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> P rte cP <br /> p /a <br /> .. <br /> PA_ - <br /> _R!FCF <br /> JUN 2 .8 1995 <br /> .. ....PUBLIC.HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH QIVISIO <br /> DEPARTMENT USE ONLY ' <br /> Application Accepted By Date h:Area c <br /> Grout Inspection By "Ci Date Pump Inspection BY Date <br /> Destruction Inspection BY Date <br /> Comments: <br /> ACCOUNTING ONLY: AID* FAC* J <br /> PE CODES FEE INFO AMOUNT REMITTED EC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 1 <br /> [I Offs- d �flAl ddrll � oFKz yT.- -'C// <br /> 7�27l45- oC�Se.�t d���l�� of w &.,es•Fs(4 o-f east <br /> A�IcP Srn a Cot.�oLe+red ",el( ccl stwuc7Ti-.- — aed <br /> '1 .ZE�R,S—O✓Sc.�eo/ dr-._(l•� O.Sf1,.. u&ea/ , �% <br /> 3fks - 6wcd d-trll.� <br /> r��i�'`tS �t fl ttrJ C��.-�1.c�/ us%%t s c�2tl 1 ks-f-a.([x'fz s•:-- '— i-c t"'. u��j�J <br />