Laserfiche WebLink
CONTRACTOR <br />SUB CONTRACTOR <br />OWNER'S NAME <br />NONREFUNDABLE 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 <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN0 Li 9 ti Atir gait IFI, g. <br />7-1:/e4/e)i 2-A e. <br />-z-7-676-rf :int-t;oy\ <br />A7 9 976 CITY Ra")/ /e 6. i PARCEL SIZE/APN1t /g 2201,1J,1 Cr. —an.to -e <br />.4 Z.-5 <br />j . ,4.-1 <br />ADDRESS ri; ri- /0 i• Ai aff 7 7 PtiONE 0 .c.,3- 977-7 70.- 9',Lacto ere( A i c, 7 0 h'.1 <br />ADDRESS 0 -01 GCE' / CA ';1 4- LICA' if 7 roZ 2- PHONE 0 ili -21i - YE9 i-- <br /> ADDRESS tra /-7/,e ad., /14. i f; pie el.JCIbirS76.?"- PHONE S 5 - if3-ST 00' <br />SAN <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />IXMONITORING <br />APPROX. DEPTH <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />3() <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />Application Accepted By <br />Grout Inspection By <br /> Date /01 -/ c./ <br /> <br />Area <br />Date 7Pump Inspection By Date <br />i , <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERViucb <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468.3420 <br />TYPE OF WELL/PUMP: J21 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL VVELL <br />OTHER <br />El VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />0 <br />A CONSTRUCTION SPECIFICATIONS i/ <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC d DIA. OF WELL CASING 2- " <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED DYes 0 No CONCRETE PEDESTAL BY DRILLER: 12 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIRROTARY ),IGER CABLE OTHER <br />DIA. OF CONDUCTOR CASING <br />SPECIFICATION <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TI ,T 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 <br />THE FOLLOWING: " I CERTIFY TH T 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.'' T •E APPLIr-4 T i NV 41 ,- li Si -VANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4664423. COMP' ETE DRAWING Al LOWER AREA PROVIDED. -......._..... <br />A rfar, <br />21/f/I-e.el <br />r <br />Signed X Title Opecqh-QAT /9761/7eper Date <br /> <br />--...... <br />-----(:), PLOT PLAN (Drew to Seale) Scale " to <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 />/41 <br />DEPARTMENT USE ONI <br />Destruction Inspection By <br />Date <br />Comments: CIAAI P A/ OC A zw-e, <br />ACCOUNTING ONLY ONLY: /ON FAC0 <br />PE CODES FEE INFO AMO UNT REMITTED I (CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />..) o'l gl — /f19 ca 1 X1 I N ti