SR0005637 - Laserfiche WebLink

Home Browse Search

Ror "N,A-1\11 1 -t-tY-v--i-IF KCi5 ?& W (ort_ o oF 60E_, occej- WtIL LO (Ara) nr*Tit oP‘st"-1-1 To c T- r t5u8/11 ITED F-6(74-- PE-S3Neartod oF in Or Te4Adut &its J fhAitat ai 19 57 Date Pump Inspection By Date APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201-388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/1 I I e..) W • OWNER'S NAME /IV/ rogkra icAri et,Ls Srr 2: PHONE a ADDRESS p 01,d CONTRACTOR ES e ADDREssif ori 0 14 AA...re:4# PHONE a SUB CONTRACTOR se. ADDRESSF ,O Lc k I FA PHONE a TYPE OF WELL/PUMP. 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL a 0 OTHER 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL a d 0 New 0 Repair H.P.DEPTH PUMP SET FT. FIRST WATER LEVEL 0 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL a , 0 SOIL BORING 3 '() 1`-/' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING D PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: 0 Yea 0 No CONCRETE PEDESTAL BY DRILLFR: 0 Yea 0 No APPROX. DEPTH PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH c'• 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 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.' HE APPUCANT MUST CALL 4 HOURS IN ADVANCE FOR ALL REQUIRED IN TIONS T 2091 -3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Title ''''--.. D Signed X Wei,t1 L 1A.ft/vi- i,' 4' r Date -7) - -7- - - C.2, ) PLOT PLAN (Draw to Scala) Scale " to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. CITY L-t-il) PARCEL SIZE/APNN (TYPE OF PUMP) 0 DESTRUCTION: LL /.1 - s') jilcu44 74' LOCKING CHESTER BOX/STOVE.PIPE AIR ROTARY AUGER fi_SA CABLE OTHER F Application Accepted By DEPARTMENT USE ONLY Date 3/N1r Area 0717C 4‘1 tru-eA, itt," 14e _01,,,(41 ACCOUNTING ONLY: AIDS FAGS '''' ' 0 -k PE CODES FEE INFO AMOUNT REMITTED p HECK /CASH RECEIVED BY DATE i t PERMIT/SERVICE REQUEST NUMB EFI INVOICE _15-0(g_ 61 ) ---- . - ;:s . i 'I A--/ c- il r- ---" -f t, ' :,•_; -, „._------Ore, e.:, Grout Inspection By Dote Destruction Inspection By 1."•‘KAA con,. tk) 1271' co