FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLIC'2110N FOR-WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE, STOOMN, CA 95201388 (209) 4663420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED cl I IComplotB In Triplkuol APPLICATION IS IIERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMI1 INSTALL THE WOW DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WHII SAN JOAOVIN COUNTY DEVELOPMENTTNIE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL IIEALTII DIVISION. JOBADORESSAIREpTAPN/ ZI `bpr7T)TM Vp 0 v CITE ''II GOdI PARCEL SIZEJAPNI i ONMEB'SNAME.AiLIIAAh I701L/[OC., FIAOCITY CMQVPlnAODRESN_ �)Z� ('AP41.I 9Uenve— PHONE itloq-347-4310 CONTRACTORAa.,pF~cez Oho ZnL. ADDRESS )8 ob W. MA REI+ LN.'4AUCA LUZZ7 %IONEE2p(056c-L 4' BUB CONTRACTOR ADDRESS HCA PHONE S I TYPE OF WELI/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnOSG-CGNNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑Nen❑TbaaU H.P. DEPTH NMP SET_FT. FIRST WATER LEVEL O RYPE OF PUMP) C ❑ OVAOPFERVICE WELL ❑ OEO%IV6ICAL WELLS � 6011 BORING QPIC S)T E B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONA C ^Y 1� A 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION •Iz5 - 1RL�IB) DIA.OFCONOUCTORCASING O ❑ DOMESTICIPAIVATE ❑GRAVEL PACKISIZE TYPEOFCASIW1STEEVPVC N OIA.OFWEMCASIWe /IIIA D ❑ PUBLICIMUNICIPAL DRIVEN DEPTH OF GROUT SEAL E SPECIFICATION T❑ryQ IMIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 71'1 M 1'\ OMUT BRAND NAMEJBf�IGB��pE E LfL MONITORING C� / S GROUT VEAL PUMPED: ❑Y- TDI. CONCRETE PEDESTAL BY DRLLERA Y- [IN. 5 APPROX.DEPTH ✓ O b5� LOCKING CHESTER 60XI8TOVE PIPE 5 PROPOSED CONSTRUCRONIDRIWNG METHOD: MUD ROTARY AIR NOTARY AUGER CABLE OTHE 6�O 1 HEAEBY CERTIFY THAT 1 HAVE PREPARED THIN A%tICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TIIIS PERMIT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWN OF CALIFORNIA.- CONTRACTOR'S IIINNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR[FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'.''THE APPLICANT MUST CAM 11 HOURS IN ADVANCE FOR ALL REGUIRED INNSSP1EC,TIIO�NSS AT 12081462) 23. COMPLETE DRAWING AT LOWER AREA PROVIDED. a,a- X /E —�eeiJ�M, TPR. �7T'M!� @ PD�Q�r�? 0.I. 7'70 ' 9 PLOT MN ID,.1.SP•Iel Se•le 'm 1. NAMES OF STREETS On ROADS NEAREST TO On BOUNDING TIIE PROPERTY. A. LOCATION OF IIOURE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OI/TLINEB 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 OR ADJOINING PROPERTY. DEPARTMENT USE ONLY nvvn..nen n...Plen eY G.I. Z 31 J7 , 7 « G,.�n I-v«nen By o.,. n.nP m•v-nen By o.I. D-Uwll.n I-P«Gen B D.I. ACCOUNTING ONLY: AID/ FACF PE CODER FEE INFO AMOUNT ADMITTED /CTIECKOMABH RECOYEDNY GAYE PEMITISERVICE REQUEST NUMBER INVOICE Y Pub.Health Sew.-Enviro.173(3196)