Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BCX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TfTLE, CHAFFER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# 3 � 3 5 F_ )k ye; k, PARCEL SIZE/APNX ^7 <br />OWNER'S NAME �- CC���Y�.1I'. (trc ��IYI/-I-� Cid✓C1 t1t1cL'+.i ADDRESS J (2/-7[?`i `/ /�y7 - /j/-/'1 I%C"C{ PHONE +M <br />�CONT <br />J <br />�1...% l.eTI /f.LADORESS(�-'F LICK Pi10NE +M �u��I <br />8V8CON RACTOR� T �'J ADDRESS � L� �l„/S rij /CN PHONE NJ/0-��3-J' /v-� 3 <br />TYPE OF WELUPUMP: . {JEW WELL <br />❑ INSTALLATION <br />❑ New ❑ Repair <br />(TYPE OF PUMP) <br />❑ DESTRUCTION <br />❑ REPLACEMENT WELL <br />❑ WELL SYSTEM REPAIR <br />H.P. <br />❑ OUT -OF -SERVICE WELL <br />MONITORING WELL X V L� JI ❑ OTHER <br />❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />DEPTH PUMP SET FT <br />❑ GEOPHYSICAL WELL X <br />FIRST WATER LEVEL <br />❑ SOIL BORING <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />❑ DOMESTIC/PRIVATE <br />GRAVEL PACK/SIZE S ' <br />I `�/� <br />TYPE OF CASING/STEEUPVC V h DIA. OF WF_LL CAS`ING <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL 7 O SPECIFICATION SC r72� <br />❑ IRRIGATION/AG <br />❑ OTHER <br />GROUT SEAL INSTALLED BY; 2eclrt/ !. 2 GROUT BRAND NAME <br />MONITORING <br />/ <br />r� <br />GROUT SEAL PUMPED: ❑ Yea )flo � CONCRETE PEDESTAL BY DRILLFR: LJ Yes ❑ No <br />APPROX. DEPTH �l� L <br />LOCKING CHESTER BOX/STOVE PIPE_ 2J FIV -5 11 - M" Ilt-i <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />�'t{ <br />AIR ROTARY AUGER CABLE OTHER I -Y/2 ( ' <br />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 <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 WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />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 <br />CALIFORNIA.' HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914653423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />(�� I i <br />Signed X !'V BG -r � �'�-Z:'"; TIti. > 1 i� l- `�47i,Lit. Data '� -/ 7— <br />Fs PLOT PLAN (Draw to Scale) Scale ' 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 <br />Grout Impaction <br />Destruction Impaction <br />DEPARTMENT USEONLY <br />Date Pump Inspection By_ <br />ACCOUNTING ONLY: AID# I FAC# <br />Data v / Area v " <br />PY <br />Date <br />PE CODES <br />FEE INFO I AMOUNT REMITTED CHECK#/CASH RECEIVW BY <br />I DAT <br />ISEAVICE REQUEST NUMnpc , INVOICE <br />0 <br />�c ss b <br />