Laserfiche WebLink
Pump InopectIon By <br />APPLICATION FOR WELL/PUMP PERMA <br />A. JAQUIN COUNTY PUBLIC HEALTH S CES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WOW DESCRIBED. TIIIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />Igt NEW WELL El REPLACEMENT WELL It MONITORING WELL 2 1,j tus El OTHER <br />El INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR El VAPOR EXTRACTION WELL <br />0 New 0 Repair DEPTH PUMP SET FT. FIRST WATER LEVEL <br />El OUT-OF-SERVICE 1NELL El GEOPHYSICAL WELLS SOIL BORING a 100 Y <br />TYPE OF WELUPUMP: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />Ig...MONITORING GROUT SEAL PUMPED: El Yee ID No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />APPROX. DEPTH 5S30 I 1 .2 7o i i le Ito' LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONIDESLUNG METHOD: MUD ROTARY AIR ROTARY AUGER Y` CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOFE WILL BE DONE IN ACCORDANCE VV1TH 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 VVORK 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 I <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE YVOFIK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />URCALIFORNIA." THE APPUCAN MUST CALL 24 HO IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 1201114511-1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Monad X AitLit;j? Title O 14Ah ..5 Date friq g <br />PLOT PLAN (Draw to Boatel Scale I • to C I <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR rmormsru <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 />Aue-- OS to4x <br />B-11 <br />tA 1).)'7 <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />s <br />S CC( <br /> <br />ConrnolE gurne.-eD06 pg cOz1oy[6 MU_ \AVath 11JPcfl A1Z - 1-2,16te.. <br /> <br />oieff \law tk iLl4A PM, 1411-1 kiiIZOWEAA Pr(We. <br />t6\10.0 W,tk MU- 15 <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />id- 4,10.14. tLtSle) <br />5 /?oot5,86 8 <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />CA FL-01)0w Prilla <br />TATC—COUNTING ONLY: AIDS FACF <br />CONTRACTOR B. Ave &—X (a {cA -Furvk <br />SUB CONTRACTOR (A*Sfese-o. 69,1avre1-f-ot 144.e. <br />OWNERS NAME F-Y6 k I <br />JOB ADDRESS/OR APNF 0 7 2 14. Yos ewu -I-t_ A OC-. CITY MO PARCEL SIZE/APN0 q 3 - 02 - (5 7 <br />0 72 L...) • Yos,,,4e. PHONE 610/ ;3 -,5 7S <br />1 CA • <br />ADDRESS <br />ADDRESS Lisq.....3 rt.Ain.I, leliekuci5„2,4.1 AS PHONE 0() 7/5 <br />ADDRESS O. III mrs-ctensotoaDuci, 5-5 2. Ici PHONE ef." 373- 1I/ <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br /> <br />Application Acoppted By <br />Grout Impfteilon By <br />Or.oftwiletn Insp.:Son Fly Dote <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />DEPARTMENT USE ONLY <br />Area <br />Dote