Laserfiche WebLink
APF -,--t ;6A r—OR iYELLiPuMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br />ENVIRONMENTAL HEALTH DIVISION <br />RO, BOX 388, WA &G—o WESER AVENUE, STOCKTON, CA 95201388 <br />(209) 4683423 <br />NOR-REFUNOA8lE PERMIT EXPIRES 1 lEAA FROM GATE 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. CHAFITER 9- 1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBBLIC/HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSOR APN,f /�` / VQ (,// CITY S1�C {L7' -[j PARCEL SIZE/APN/ <br />i67 z� �vr (.-tt.� �^� .j Sit 4/70 7 <br />OWNER'S NAME 7L r;;, j�yY— �- eLh ADDRESS �Cr4k<tia.'� U—✓�-! /��4.�.J�— PHONE( ZT 7-7/1, <br />CONTRACTORyor [� Y.y ADDRESS,4/t -L L, }1co PHONE/ 70-- 3 ',"90 <br />SUB CONTRACTOR_ / / r� ADORE SS/Il I..,���.-y � �L..Lt M 77'74)uc: S—S`f?l '7 PHONE f f".� 727G <br />TYPE OF WELUPUMP: ❑ NEW WELL <br />❑ REPLACEMENT WELL <br />❑ MONITORING WELL R <br />❑ OTHER <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR <br />❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL ! <br />❑ New ❑ Repelr <br />H.P. <br />DEPTH PUMP SET FT. <br />FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />❑ OUT -0F -SERVICE WELL <br />❑ GEOPHYSICAL WELL I <br />❑ SOIL BORING <br />q <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS R1S(�I fJL/'G %�/�� �I rv.. k- "" �C r♦L�d <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION •` DIA. OF COfIDUCTOR CASING CLx.l cv� <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA. OF WELL CASING <br />❑ PUSUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />❑ MONITORING GROUT SEAL PUMPED: ❑ Yea ❑ No CONCRETE PEDESTAL BY DRILLER: Cly. ❑No <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br />PROPOSED CONSTRUCTIONIMLLING 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 ANDIJ <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 WHICI <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEFITIFIE;� <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH!C. THIS PEP.Mrr IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'e COMFMSAT/0N LAWS OF <br />CAUFOR �THCANT MUST CA�aHO /IpV�CE "'r At�,TM ;rt NAPEC !IOhf wr i2061 a ,3A23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SlpnedX ) / [(,4 Title S/�- (�"`!�lJ r,7 �i Date7 AT <br />PLOT PIAN IDr— to S -W Sul• 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 6. 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 />Application Accepted By bKrj t " 1, y/•� <br />Grout Inspection By <br />Destructlon Inspection By�M-�^� <br />rf <br />DEPARTMENT USE ONLY <br />Det. Are• J./ <br />Pumo Inspectlon By Date <br />ACCOUNTING ONLY: AID+► FAC# 11 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHE ! ASH <br />RECEIVED BY <br />DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3� <br />