FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

i i Iliil 41' t APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION w 304 EAST WEBER AVENUE, STOCKTON, CA 95202 `�`--r�-f��..L• �ti Com!��1 1V� (209) 468-3420 w P L L��Jyr�1�`,,I�jJ WON-REFUNDABLE PERMIT EXPIRES f YEAR#ROM OA E ISSUUEEEB 1 APPLIChT 9 HERE BY MADE TO THE SAN JOAOQIN C FOR A PERMIT TR CONSTRUCT ANOIOR INSTALL THE WOW CRIBE4.T1 APPLIQA7 ISMADE IN COMPLIANCE WFTI{SAN JOAQUIN COUNTY DEVELOPMEE11IT TITU.CHAPTER 8-1115.3 AND THE STANDARDS OF 8AN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH bRVISIOH. JOB ADDRESSOR APNN �3 (�D may^— D CITY•Ii+(J D - --PARCEL RIS�PNR � OVVNER'S NAME �. i'�r'-�'j,�2 d A .. ADDRESS 2/Z/+- C 1 .-•fPHONE CONTRACTOR ADDRESS- 3L17 �l;! I� �J�LIC !�.y PHONE RUB CONTRACTOR ADDRESS ICN PHONE N S TYPE OF yYELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER - - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTK]N WELL N J ❑New.❑Rapatr H.P- DEPTH RUMP BET . FT. FIRST WATER LEVEL D (TYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL N. ❑ SOIL BORING B DEBrRucrroN: `DIS C Ike ^ �✓1 D 1C�i�0127 lA I)t—'1-� -- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION GIA.OF CONDUCTOR CASINO 0 ❑ OOMESTIC/PRIVATE []GRAVEL PACK/SIZE TYPE OF CASINOMTEEIUPVC DIA.OF WELL CASING. O i ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATRONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND,HAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑NO CONCRETE PEDESTAL BY DRILLER:❑Ye. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONWRILLUNG(METHOD: MUO ROTARY AIR ROTARY AUGER CABLE OTHER I HERIEBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULER AND REGULATtONB OF THE SAN JOAQUIN COUNTY. BIOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED SHALL O PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOVING• I C IFY AT IN TI RFORMANC OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMrMBATION LAWS OF CAUFOIWIA.' C MUST C NOURB IN ANCE GOR ALL REGUIiim DISPECTlONS AT 1205!�pa{27, COMPLETE bRAW{N6 AT LtT1{4ER AREA PRD signed k 71Is an OT PLAN(Drew to Beale)Scale 'to q 1. NAMES OF STREETS OR ROAOS REST TO OR BOUNDM THE PROPERTY. !• LOCATION OF HOUSE SEWAGE DIBPOBAL SYBTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED a. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOMMG.'.PROPERTY. DEPARTMENT USE ONLY Apppcettan Aaeepted By ` ONe CI f 1 Area . Grout Impectlen By Dwo Pump Inepeotten By Data OnetnmVen Inorwthm By- ( n l J�'` ,,J�� + Oate.�, -f �� Ce,n-ftw rI �` r\- rI `, i W V lY\ "1 �Q' f of LC3-ce Y K�reAd -13 ACCOUNTING ONLY: AIDN FAC# FE CODES FEE INFO AMOUNT REMITTED CH ECKNMABN RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 3560 a. 5 4 Pub Health Serv.-Envira.173(1/97)