SR0019174 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL►PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-M (209) 469-3420ORIGINAL NON-REFUNDABLE PERMIT I 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 8-11(115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. 'Z105 CITY -10", t4N Q.PARCEL SIZE/APNIJOB ADDRESS/OR APNI OWNER'S NAME xXz-0 PHONE 0cf �sCONTRACTOR ADDRES6 SUB CONTRACTOR ADDRESS .A' UCS PHONE 0 TYPE OF WELLIPUMP: M NEW WELL ❑ REPLACEMENT WELL MONITOPoNO WELLI W' 'n uN-(O ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLJ ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ITYPE OF PUMP) j s, ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL I In SOIL BORING lQ .JO.I I OC it`yS t p ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION U . LS \ A DIA. OF CONDUCTOR CASINO N a, ('\D ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE r J TYPE OF CASING/STEEL/PVC 5c.�% I'Ia1 Fti� DIA. OF WELL CASING L� \ �D ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL Z •rS 1' «rT SPECIFICATION i�� A `�•••1t,^'n• 1 R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BYGROUT BRAND NAME E MONITORING ^� GROUT SEAL PUMPED: ❑ Yee ® No CONCRETE PEDESTAL BY DRILLER: ❑ Yw []No APPROX. DEPTH LOCKING CHESTER BOX/STOVE RPE YL PROPOSED CONSTRLICTION/DIYLLING METHOD: MUD ROTARY AIR ROTARY AUGER i • CABLE OTHER R 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iS ISSUED, 1 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T 24 Hp/U_lti IN ADVANCE FOR ALL REGUMED IN1SPE�CTTIONSAT 12001403-.X423. 403421. COMPLETE DRAWING AT LOWER AREA PROVIDED. Stoned X , \- Title �iSw.\T �JIG(1C� t Data --i T\l PLOT PLAN (Draw to Goals) Seale ' to 1. NAMES OAF STREETS OR ROADS NEL 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 WALLS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Application Acoepted By. Grout Irnpectlon By. (/ Date Pump Irrpeetlon Deatruetlon Impaction By _ - [ 6e i Date � ` O � � Area V r Date ACCOUNTING ONLY: AID+t FACT PE CODES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED BY DATE tEI1MiT/SERVICER ER INVOICE 3So 2850lap1