SU0013724 - Laserfiche WebLink

Home Browse Search

APPLICATION FOA WELLIPUMP PERMIT v SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RO, BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95'201368 (209)4883420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CEmpletE M TrlpDut31 APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNT'FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE M COMPLIANCE VVPTH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,CHHiAPTER A-1116-3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION, JOB ADDRESS/oA APN/ ^L \ �Lj,y q� � ADORERS C�y PARCEL SIZ/APFI OWNER'S NAME PHONE CONTRACTOR ADDRESSV Pxv.)W LCJ W�kU\ PHONE#�; , SUB CONTRACTOR ADDRESS LIC# RHONE TYPE OF WELLRVMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WTu I ❑OTHER INSTALLATION Cl WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL ¢J Nwv❑R�efr H.P., -2)C DEPTH PUMP SET,:�L) FT. FIRST WATER LEVEL O R OF PUMP) ❑OUT-0P-SERVICE WELL ❑ OEOPKYSNCAL WELL# ❑ BOIL SONNO S ❑DESTRUCTION: INTENDED TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 ❑INDUSTRIAL ❑OPEN BOTTOM LH DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING J 1� DOMESTICUPNVATE P(ORAVEL PACK781ZE U TYPE OF CASINOlSTEELRVC DIA.OF WELL CASINO ❑PUBLICUMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑IRAIGATIONIAG ❑OTHER GROUT SEAL WRTALIED BY GROUT BRAND NAME E J- ❑MONITORING GROUT SEAL PUMPED:❑Yr ❑Nn CONCRETE PEDESTAL BY DRILLER:❑Yw Elm. u APPROX.DEPTH ��, LOCKING CHESTER SOX/STOVE PIPE S -t PROPOSED CONSTRUCTION/DRLIINO METHOD: MUO ROTARY AIR ROTARY AVOCA CABLE OTHER +Q 1 HEREBY CERTIFY THAT 1 HAVE PREPARE D THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITSA H N JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN CONTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFES THE FOLLOVYRKi:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK TOR W 41CH TNS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA* CONTRACTOR'S HIRING OR SUBCONTRACTR40 SIGNATURE CERTIFIER THE FOLLOW O: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SURJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA -" THE APPLICANT MUST CALL 24HODU1M IN ADVANCE FOR ALL REO11111 POCTTONS AT 130814484423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 81Enrf X TIN. Q�� Det• \��p PLOT RAN brew tp S-k)S"(s 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISPOBAL SYSTEM OR PRDPOBED 2- OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIREC710N. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF8 AND LOCATION OF ALL EXISITNO AND PROPOREO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALK B. ON THE PROPERTY OR ADJOINING PROPERTY. OR 72 ENI 2,0,000 1 a�5 Q VAR 19 1996i .. P.Wio'HtAL.T1,SFRVICE CWRONMENTAL HEALTH DIVISIrr' � DEPARTMN41 WE ONLY APPRc+tbn Atoepted BY D.. C � Oro U!Irtpectbn By Oete Pt rn P-flb 8Y � Dete G Dstr—tbn I-pe )on By bete Comm4nle: - ACCOUNTING ONLY: NDA FACT PE CODES F AMOUNT REMITTED F1EC M11EN RECEIVED BY DATE "WATMERVICE REQUEST NUMB91 IH VOICE