SR0023341 - Laserfiche WebLink

Home Browse Search

/"`'4PPLICATION FOR WELL/PUMP PERK "� SA,. oOAQUIN COUNTY PUBLIC HEALTH SEr.,/ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompkils In Tripliestel APPLICATION 18 HERE NY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE Wulf SAN JOAQUIN COUNTY DEVELOPMENT CITY PARCEL BIIE/APNN TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. J08 ADORE99lOR APN/ �3LM9 nvRr�^ 0_F Fr!"Pti,�oj S+ &A,<-MAOS OWNER'S NAME ll , V 8 PHONE N CONTRACTOR , ADDRESS �22l_SYl-3-rt�..�P fl urt 'g(,7asaPHONE I CIQ—1J J? {�' �l Sue CONTRACTOR 4 C'. ADDRESS 23 1LOS Lica r2PHONE aAV�1-8Z a9 TYPE OF WELL/PUMP: ❑ NEW WELL REPLACEMENT WELL ❑ MONITORING WELL a ❑ OTHER © INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL a J ❑New❑Repel,/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMPI (3OUT-0F-SERVICE WELL ❑ GEOPHYRICAL WELL a 1 SOIL BORING ❑DESTRUCTION: ✓✓ __ INTENDED USE TYPE OF WELL CONSTRUCT10N SPECIFICATIONS 1�. A © INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I� ILO �OW ` ' DIA.OFIfCJONDUCTORVrINO O © DOMESTICIPIIVATE ❑GRAVEL PACKIBIIE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASINO b C) PUSLICIMUNK:IPAL ❑ORIVFN DEPTH OF GROUT SEAL SPECIFICATION R © MRIGATIVNIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E © MONITORING GROUT SEAL PUMPEb: V- Ia Ne L�Cr 'W CONCRET pE`p BTAL 8Y DRILLER:❑Vw ❑Ne S APPROX.DEPTH V — LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONITRUCTIONIOI ILLINO METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER VVV I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 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 WHICH THIS PERMIT IR ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'I HINNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T14I8 PERMIT 18 18RUED.I SHALL EMPLOY PERSONS SUBJECT TO WORRMAN'S COMPENSATION LAWS OF CALIFORNIA.' INOPPUCANT MUST 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPEC NS AT 1409-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED Bianed X Tltte bete PLOT PLAN Nrow to Sahel Boole 'to t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 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 S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY On ADJOINING PROPERTY. oj p; To w 41 Cho ............ .. . . V • .. .,. _... .. 'jut20DQ ...,. .. 7 OLy93Y1' .. QUy : gAN JOA NG PUBLIC HEALZN __ _ ENV1R4i�M�NS AL HtiALZH.�IV4s4�f� DEPARTMENT USE ONLY c� Appnrollon Accepted Gwul ImpecOon by - Dote Pump Irnpeetlen By Dole D-trkwtlon I NPoctis&m1S�yData Comments: '�1147',J1Mt ACCOUNTING ONLY: AID# FACE PE CODES FEE INFO AMOUNT REMITTED CHECK#R:ASM RECEIVED BY DA PEAMIT140MCE REQUEST NUMB INVOICE Purl.Health Serv.-Envlro.173(1197)