Laserfiche WebLink
CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL // <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />IAONNORSNO <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />A4:44_L - <br />... <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete hi TflpBeate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON( DESCRIBED. T1118 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1153 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APHI : I r"-Nt- ti r CITY i--fry,u1-e‘..,4 PARCEL SIZE, c2 )-- - .21 <br />SUB CONTRACTOR V l'.2) <br />CONTRACTOR <br />OWNER'S NAME C i; J. k. ft"? ,t4 , ADDRESS t?, <br />C C <br /> - 71..o <br />ADDRESS <br />ADDRESS 51-&' 4•51-1' <br />`F.5"-L. ,• - L-A <br /> <br />KC-4. C tk-r-vri• 3'-f" <br />C 2 uCF PHONE ; <br /> LICE 4ALL 2 X. PHONES ;4,5 1 Li <br />PHONE e c.,57 <br />‘,ti <br />TYPE OF WELL/PUMP: 0 MONITORING WELL 5 0 OTHER NEW WELL <br />INSTALLATION <br />0 New 0 Repth <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />(TYPE OF PUMP) <br />0 DESTRUCTION! <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yew ON. <br />LOCKING CHESTER SOX/STOVE PIPE <br />AIR ROTARY AUGER <br />A <br />DIA. OF CONDUCTOR CASING /3 <br />DIA. OF WELL CASING <br />RD r SPECIFICATION <br />GROUT BRAND NAME E <br />CONCRETE PEDESTAL BY DRILLER: Oyes 0 No s <br />S <br />LI <br />L- <br />.1...- <br /> CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORE 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 VVON( 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 THAT IN THE PEFIEORMANCEOF THE WORE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAIJFORNIA." T7 APPUCANT MUST CALL 24 HO IN DIVANCE FOR AU. REQUIRED INSPECTIONS AT 120114013423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />L <br />/Maned X - Title t'-j ,er_ / 6 e, 4_....>'...:,— )67 e . . ii6 .5 - r. , 2 Date <br />PLOT I PLAN (Draw to Seale, Scel• • to <br /> <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <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 MOWS OF ONE HUNDRED FIFTY FT <br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />ApplIcetlers Accepted By <br /> <br />1A-1/1/1A.11A <br />DEPARTMENT USE ONLY <br />Date 5. )3 )/00 Area <br /> <br />Grout Iropectleo By Date CC, Pump Immection By Date <br /> <br />Doetructlen InepectIon By <br /> <br />Date <br /> <br />Commeote: <br /> <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE -PERMIT/SERVICE REQUEST NUMBER INVOICE <br />'o) Cel s.(20 -c <br />( c/3 i oo c/; SR 0 0 2-2- 9,6, <br />_ <br />Pub Health Serv. - Enviro. 173 (1/97)