Laserfiche WebLink
Application Accepted By <br />Grout Inspection By -.1AA.48.AS-C-Lin <br />Destruction Inspection By <br />Comments: <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Dale a (2) Are. <br />Date <br />Date <br />'APPLICATION FOR WELLIPUMP PERMIT , <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPUCATION 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 SAN <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 />S f ) 0 C L, A ,, 0:tAne I F , \ JOB ADDRESS/OR APPLE • ... ''' - , 4 • , II ‘• I-1 : • ' '' 01 j CITY 516 ( i-°s PARCEL SIZE/APN# <br />OWNER'S NAME -, ''' vl . , 1•,,,A C, „.itj i)4' <br /> <br />(4 4, r A vtit .1 I <br />1 <br />to') ADDRESS ...5, t-C C l'S ti):1 eA PHONE .U0 9) 6 <br />CONTRACTOR v I 1. '''' ' I ' " ADDRESS 1:Ce.rer c(ty., cA Lic#1.V.) Z -1- PHONE *(I g )L-ie4 <br />Li .. Li 160 . re a .,- <br />../ SUB CONTRACTOR ADDRESS LIC# PHONE # <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER <br />El INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL * <br />El New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 0 SOIL BORING L.- '-',-- iir• V ,... t', <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEELJPVC <br />DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL f r- <br />SPECIFICATION t\le rC C 1 -el 1- <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLFR: 0 Yee 0 No <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <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 RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA." THE APPLICANT MUST C 24 HOURS IN ADVANCE FOR AU- REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title <br />A <br />Date Z. / Li- 1 <br />PLOT PLAN (Draw to Scala) Scale " to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR 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 <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />ACCOUNTING ONLY: AIDS FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />360 11) .3‘ 9 -3c./( 144,10/1_ 1 2 .1 6 -`15 <br />' Is P • 6 6 \ 3— • ..... <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />12'MONITORING <br />APPROX. DEPTH <br />El OPEN BOTTOM <br />o GRAVEL PACK/SIZE <br />El DRIVEN <br />0 OTHER GROUT SEAL INSTALLED BY \I a r. .‘ <br />GROUT SEAL PUMPED: 0 Yee aro <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER CABLE OTHER 1:- e_