Laserfiche WebLink
0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # )113. SOIL BORING ( <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 <br />Date /.1kAg-V Application Accepted By <br />DEPARTMENT USE ONLY <br />igb6 A.1-0 <br />Date <br />a <br />Destruction Inspection By <br />Comments: • , <br />t I.( <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 UCENSED 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 CAUFORNIA. 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 />CAUFORNIA.' THE APPUCANT MUST CAU, 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091488-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Title priv <br />PLOT PLAN (Draw to Scale) Scale " to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTUNE 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 />Grout Inspection By Date ) Pump Inspection By <br />Signed X Cs) 1,17 +1/1/LI Date 1-/// 7rn' <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 />Date <br />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 />O2/q7 1 <br />JOB ADDRESS/OR APN# <br />1' St k4S+ 111-27- c4ree..4- <br />0VVNER'S NAME CC/ <br />14 <br />WV) CIA , <br />CONTRACTOR S 4 1114 Eek 11.10 Alit.'3•1040- <br />SUB CONTRACTOR 1 tC-PN2 X Eik‘i PC*AsiliN4-4'44 <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 APPUCATION IS MADE IN COMPUANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBIJC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />CITY -1-tro-t-.4 <br />ADDRESS p.e Sox .500 jo <br />ADDRESS 1410 (SIC e•-‘1•1 <br />ADDRESS 155 ti'n,vt`siz-bucilosqz-+ <br />UC# 5 1°6 'C PHONES Z" - 57-9' 7-21.1 <br />PARCEL SIZE/APN# <br />PHONE # 41N5 2-b(F3- O(3(' <br />jc"NI-15 4-(0 <br />DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING D <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION i? <br />IRRIGATION/AG Al OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME iit-CA1 ',ir C 4.1 (4.../PlAt E <br />Ar MONITORING GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DFULLER: 0 Yes 0 No S <br />APPROX. DEPTH 1 0 't-eR-+ LOCKING CHESTER SOX/STOVE PIPE S <br />PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER D1.- y+1St-11.4\4, <br />ACCOUNTING ONLY: AID* FAC# 3s- a I <br />PE CODES FEE INFO AMOUNT REMITTED CHE CASH RECBVED BY DATE PERMIT/SERVICE REQUEST NUM8131 INVOICE <br />1,0JF Ao--- tifittiqk s c, Obooh'IR 0.?:74 -7 4+ <br />sa 6 60 S l'.(.