Laserfiche WebLink
APPLICATION IS HERE BY MADE TO THE <br />JOAQUIN COUNTY DEVELOPMENT TITLE, <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVILtS <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468.3420 9 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED <br />(Complete In Triplicate) <br />SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAT <br />CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNa 43 1 5 NTERLoo Ro p‘b <br />" <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC P <br />DEPTH OF GROUT SEAL <br />' to PLOT PLAN (Draw to Soare) Scale <br />I. 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, AN,/ WALKS. <br />Pump Inspection By <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Deatruction Inspection By <br />Comments: <br />Dati/ 3,ra <br />Date <br />Date <br />PARCEL SIZE/APN. <br />OWNER'S NAME ECZU- LION-1 EN,' TER ?Z‘ <br />CONTRACTOR 0_,Arts4 BV-LkiNr ;\1\a""VTA-11--. ADDRESS 1-0 BOA- 2.4,9k SCNI(!st4A CAL1Ca <br />SUB CONTRACTOR C-19seGel b L—L-11\--)61 <br />CITY ST 0 C.K.Toil <br />ADDRESS P.O, ROL 60+9, CA RC c-N CA 9c;71-9 PHONE #(9) (044;' 93Ca <br /> PHONE / 0C-043T' 4t: <br />ADDRESS 150 i-to06, *f-TNc UC, 4g5 165 PHONE ,$'(9Z5) 3 13-79a <br />TYPE OF WELL/PUMP: Se/NEVV WELL <br />El INSTALLATION <br />ID New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT WELL MONITORING WELL a ofta <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 GEOPHYSICAL WELL I <br />OTHER <br />VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL <br />SOIL BORING <br />H.P. <br />0. OUT-OF-SERVICE WELL <br />GROUT SEAL INSTALLED BY (1r ; Ilex^ <br />GROUT SEAL PUMPED: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE, <br /> AIR ROTARY AUGER X. <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING 2 )1 <br />SPECIFICATION Cc_in 40 <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: ErVara 0 No <br />CABLE OTHER <br />INTENDED USE <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />PiIRRIGATION/AG <br />a MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />5rEN BOTTOM <br />aGRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />*21 it. <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />52? <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 RULE <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 <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.' THE APPUC T STCALL HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209) 499-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />#4ff .A4....14ehd...'d f td Signed X Title peraa/7‘ 777a4Cefer- D•te kb.e/53'7 <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Post-it' Fax Note 7671 Date ,..y-> jA.,:i p#a feso. j <br />To A (y CC) ( ) From , <br />Cr cr_ <br />Co./Dept. (a_ik) ,2)(c i Co. c; If 17E /VI/ / i) <br />Phone # Phone # <br />Fax # /.17_. „or ..(, it, Fax # <br />ACCOUNTING ONLY: AIDK FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKK/CASH RECEIV D BY , DATE _P_ELIMIGIERIQ UES.L.BThVISE INVOICE <br />330 1 g I . 0° I -7- 54+ id, g A 5-RpoZC -3 8 9- <br />- ___ <br />,