SR0005517 - 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 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,,,,jjJJ��(` APPLJCAI IdR IS HERE BY M/Lt, E� 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 DEVELO/y� TITLE, CHAPTER 9-1111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. PE CODES FEE INFO AMOUNT REMITTED JOB ADDRESS/OR X CITY�%� '1 i1 PARCEL SIZE/APN# I L 7 O) I �.A 1� j�Gi� /� ADDRESS C -P 00/ �OI -fes 1�SA �,�4 OWNER'S NAM �— Je�f� t//'DY� s �-C/ IOf ��Q�PHONEI 7� C ADDRESS 147 98 W //�[S FIV l UCXYL�809 PHONE R SAO 5 - Qt/ CONTRACTOR SUB CONTRACTOR VG (i OI-� /y L �1 r ry� ty1 �1'lh^� �y rQ rl f A r� y I /� ADDRESS L C 1I \19 LICX �J Z PHONE TYPE OF WELL/PUMP: ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS (.i�'� ❑ OTHER ® INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # 1 ❑ New ❑ Repel, H.P. _ DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) - ❑ OUT -0F -SERVICE WELL C1 GEOPHYSICAL WELL .f C3 SOIL BORING 8 1 e ❑ DESTRUCTION: 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / n DIA. OF CONDUCTOR CASING K44 0 C1 INDUSTRIAL El OPEN BOTTOM DIA. OF WELL EXCAVATION 1-11d 0 ❑ DOMESTICIPRIVATE ❑ GRAVEL PACK/SIZE"-;-s.,A, TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING SPECIFICATION 0 , 026" ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL � V ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY LJpp/', I I/� GROUT BRAND NAME E CIN. �) MONITORING GROUT SEAL PUMPED: ❑ Yee I01 No CONCRETE PEDESTAL BY DRILLFR: Yee S S APPROX. DEPTH Y) 'VL LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTIIUCTION/DMLLING METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE: OTHER O I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWI 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 H A C MUST 21 HO UIIf I ADVANCE FOR ALL REQUIRED I�I-NI�SPEG ONE AT 120Y 469-34-23. COMPLETE DRANANG AT LOWER AREA PROVIDED, '^/ Signed X Title [� ` l `✓ PLAT PLAN (Drew to Sole) Sole V ' to 1. NAMES OF STREET 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. ..... ...... .. �r 1� ]... ....... ..... .............:.......? ... .... _. ............. :............................................. : ...... ... ....... IL....... F - - - DEPARTMENT USE ONLY 1r Application Accepted By Dote ` Area Grout Inopectlon By Date Pump Inspection By ,. ie�I�r Destruction Impaction By Date Comments: W ACCOUNTING ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMSER INVOICE S�o00SS