FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT *SAN JOAQUIN COUNTY PUBLIC HEALTH SE IMS ENVIRONMENTACHEALTH DIVISION P.O. BOX 388, 344 EAST WEBER AVENUE, STOCKTON, CA SS201-M (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 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 SAt JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COU�N..Tj PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/_ J I S Ly d7(z 1rr- l�G� CITY ✓J_ (JC4--jen PARCEL SIZE/APN# OWNER'S NAME 1/ f/,V ]C—V ADDRESS //9c�a S_• G�/�/Q,*t� /�(,/, G�fC..� PHONE! /Q.��L,�'1!�� I CONTRACTOR_ 1J yli �rl,�(/1�► ADDRES6�•��k�, �IQC�i� ` LICK2X71' PHONE#j411(—z SUB CONTRACTOR �� ADDRESS UC# PHONE# TYPE OF WELLIPUMP/. E.J NEW WELL 11REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL/ Va'19 TTYPE OF PUMP) ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p 11OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1 r DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC VL DIA.OF WELL CASING 9 0 D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL j)IZ I e-L.OWL SPECIFICATION 'L R ❑ IRRIGATtON/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME O/1J&4 E MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Year ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DAIL11NQ METHOD: MUD ROTARY AIR ROTARY AUGER_—CABLE OTHER I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 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 CALIFORNIA.' THE `jPPPUCANTTJMUSTT,,C/�LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20e)46111-3423. COMPLETE DRAWING AT LOWER AREA PRROVID]E/D�. Signed X _ ef-ellzze4eGi (41d 4✓d Title /' U/�F-. Fi / Date !/o"'L l �s PLOT PLAN (Draw to Sulo)Sule 'to /. 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 OR ADJOINING PROPERTY. ... ...;. ...: .... .. .. .. .. .. ............... ..... ,..... ............... ...... .. .. .. .. .. ............................................... ................1 ..................................... .... .......i.......i.... ..e. ......:......'.......:.....;......�.............:............. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ;... 9 .. __. .... ;......:.............:......:........................... ......:..............?.................. ......P.............i.............i........... .... .............i.............?................................'............ ...; DEPARTMENT USE ONLY Application Accepted Byn � q Date v1(//1f"I 1/I _Area Grout Inspection BV-' K(7 v/j-Q Date �' b� Pump Inspection By '�,1_T_l Date Oeatructlon Inspection By - Date Comments: - ACCOUNTING ONLY: AID# FACT PE CODES FEF INFO AMOUNTJOWITTED CHECK//CASH RECEIVED BY DATE POWITISERVICE REQUEST NUMBER INVOICE