Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 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/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLCHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. E, <br />110 0, Fi.1.6-c-v. CITY <br />57,t, j6., <br />PARCEL SIZE/APN# )T4 ( 1,1( &I, a( __. <br />(-2--t-A Dt2k ti( .45 <br />SUB CONTRACTOR <br />TYPE OF WELUPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL # <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br /> <br />OTHER <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br /> <br />0 <br /> <br />(TYPE OF PUMP) <br /> <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # K_SOIL BORING <br />0 DESTRUCTION: <br /> <br />OPEN BOTTOM <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION <br />.4.-eli <br />DIA. OF CONDUCTOR CASING D <br />GRAVEL PACK/SIZE <br />TYPE OF CASING/STEEUPVC DIA. OF WELL CASING D <br />DEPTH OF GROUT SEAL <br />4/ fr <br />SPECIFICATION I R 0 DRIVEN <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME k I-WA rld ( dill e4tr E OTHER <br />GROUT SEAL PUMPED: El Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No S <br />S <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: 1 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 CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF--- <br />CALIFORNIA." T E APPUCANT MUST-CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECT NS AT 12001468-3423. COMPLETE DRAWING AT LOWER AREA PROVI ED. <br />/ád -17e/C Data &5 - <br />JOB ADDRESS/OR APN# <br />OWNER'S NAME <br />CONTRACTOR <br />r I <br />ADDRESS i9----7iL, t.... 116(.4 <br />ADDRESS VC41-04.1J...-r- 6--it LIC#CA:t PHONE # 540-6.-CS-ot7/5- <br /> ADDRESS LJC# PHONE # <br />PHONE # <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br /> <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER X_ CABLE OTHER <br />2S) <br />Title / <br />PLOT PLAN (Draw to Scale) Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />I. <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> \_C d•-se- Date I(C --(AS Area CiLf <br />Grout Inspection By _ 414.- qate 7),3 Pump Inspection By Date <br />Destruction Inspection By <br /> <br />Data <br /> <br />Comments: <br /> <br />I ij-39-S <br />01 LAAS -4- PA tiO h <br />litiruteiut-tv-Qta 31 3 -3 <br /> <br />CeS '915 -0 -1--1 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECIUMASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />.31 c 6 oat 7 .,..wk...___ i-jt5 OOS 17 Ce; <br />C 0\060 !S\11