FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 AND THE STANDARDS OF SAN JOAQUIN COUNTY $V PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN e Li N R O PA CITY E(�1A m PARCEL SIZE/APNI 14r.-73 AcZP OWNER'S NAME rE,P.T ►y�}A��RT�Tay �►� ADDRESS _ O e5 EV��p1Q . PHONErk7-4,0-7 -0 3 7_'4t—S4 C�t�CONTRACTOR (1 n ' S ADDRESS2-1/pok `z\\If—g CrW.R• PHONE IU8'59/y4 SUB CONTRACTOR / Tr?-fj ADDRESS 2,31h Q,%NLI913. C/ a PHONE I ��L — 209—=—•_,57,9--r,,� S7b} TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N_ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ El ElRepalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL. ® SOIL BORING e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p A A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION p „ DIA.OF CONDUCTOR CASING R D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC N.K. DIA.OF WELL CASING Nye Q D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O/ SPECIFICATION N r Pt. R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY pS GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ®Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ®No S APPROX.DEPTH �'/ LOCKING CHESTER BOX/STOVE PIPE S 4( PROPOSED CONSTRUCTION/DRILUNQ METHOD: MUD ROTARY AIR ROTARY ALGERIA NS, 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 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 THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' E APPLICANT MUST CALL 24 11r18 IN ADVANCE FOR ALL REQUIRED INSPECTIO�l6.AT 12091 4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIQr d X ! L� (/L L• �� Title_1 X6. (CL S Date PLOT PLAN(Draw to Scale)Scale .0 'to 2 S J7 1. 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 6. 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. APp�ox►Mai-rG-- �c�ATlo/1 ... .. . .:...... .. . .;. Ca++rrt�rt�re rl Gu�t�r. �..► ' I DEPARTMENT USE ONLY 1� � Appllcatlon Accepted BY�L�t Date I t+'I Area •a C/1 I/J(/n0,(� Grout Ir _ u actlon B /1SSr��•" P Y Data Pump Irupsctlon By Date / Destruction I-pa^ctionoBy'�Z , Data ' Comments: 1`� t/C,y'1^r�.S ACCOUNTING ONLY: AID/ FAC/ C / D/ PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY D TE PERMIT/SERVICE REQUEST NUMBER INVOICE 0 0 Cl-Ll Sz Ir,01 1 eo 0�0 F(�-ak s-(AA' /Vt Lk,4,1, lir�k-o, IL f 0 • 4� 1gI5 �