FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL/PUMP PERMIT SAI )AQUIN COUNTY PUBLIC HEALTH SE, CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete["Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATON IS MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9--1115.7 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC'HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRES"R APN/ � `US WC"S/ Jl�rn ir•.rn h !fG'� ✓/: CITY UG rc /G I PARCEL SIZE/APNI !�2 OW7JEft'B NAME 1./l ru/'On /i'�n///I a'/(; //J ADORES8. 66V/ iJ�r.� J �q �!.^o Ae-�_»PHONE/�S/O�S`I�'�6/S CONTRACTOR r7r��nr j'4 li �//!/�!` -'T AODRE66�1/S/O/J17Grr is f../,Wh(.'..�A,.,, CI s-7;9� 1167 PHOIaE,elle � 3[ick SUBCONTRACTOR_ /rr1_%S%Un ..)lJTn Ln( ADnncs9-"(7Z1_ay SG.7/., e est LACI6J6�/ RHONE le } '/ TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J ❑N—13 Fe.T, H.P. DEPTH PUMP SET FT. FIRST WATER LEVFIL O rTYPE OF PUMPI qIpP ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I 10-SOIL BORING I B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 A ❑INOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ((13 Y./'2'r�- DIA.OF CONDUCTOfl CASINO D ❑OOMESTIC/PRIVATE 13 GRAVEL PACK/SIZE TYPEOFCASING/STEEVPVC- .,JJGG I/�//rn,r�[i,:� DIA.OF WELL CASING O ❑PUBLIC/MUNICIPAL VORIVEN DEPTH OF GROUT SEAL_ �fe/n'-SLJ t-� Si'ECIFICATION R ❑T�IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Pr-, IC/0l'1 GROUT BRAND NAME E yt MONITORING GROUT SEAL PUMPED:11Y_ 19Ne CONCRETE PEDESTAIL BY DRILLER:❑Y- ON. S APPROX.DEPTH yo-sem Ff LOCKING CHESTER BOX/STOVE RPE /, S PROPOSED CONSTRUCTIONMAILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER {-hw/-I-66rC 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN 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 FOA WHICH THIS PERMIT IB ISSUED,1 SI4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLIO VNNG: 1 CE IFY THAT IN THE PERFO-:TR_MANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO+ORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T' TT NT MUST C/�t.Int/ #6 IN ADVANCE FOR ALL REQUIRED 1NS/ECCTIO{N4 AT 1205)4SSJE2S.COMPLETE DRAWING AT LOWER AREA PROVIDED. SIor+IX tin U PLOT PLAN(D-to ft..] to 1.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 OISFO AL SYSTEM 8. G.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WIT/11N DRUB OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINT G PROPERTY. r : tl I _ 1 DEPARTMENT USE ONLY Appy a I..Aced BY BF LI/M 23-.I OHS_ Arr Groru IMpoetkn Dots P mp I-P-1—BY D . OMRnw1IOn IrwPKRlon BY DIG• � I Cnmme,MR�: ACCOUNTING ONLY:_AID/ PAC PE CODES FEE INFO AMOUNT REWITED CHECKIICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 1 351 otia 2�' a 2G 5 Pub.Health Serv.-Enviro.173(1/97)