Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT j <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTH SER►. _S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201.988 <br /> (209)4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED C <br /> (Complete IS Triplicate) <br /> 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 S, <br /> JOAQUIN COUNTY DEVELOPMENT / <br /> TITLE,CHAPTER 9-111/6.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN/ Gt2() W. Char-i{I/r' WAV CITY PARCEL SIZEJARJ/ <br /> OWNER'S NAME Eq ViLn En-�C"pri5ft LLL_._ ADDRESS P.0. 6 bay9 C..J.n CA 9075/7 PHONE/ <br /> CONTRACTOR CA F-- 4-- ADDRESS ��/ MN <br /> PHONE/767-97S-yQELn2S , L.04 S <br /> SUBCONTRACTOR (;�req '0-i", r 7 ADDRESS9,$-D /{nw .d. A4,4—? UC/ PHONE/7�s-313-541 <br /> TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> ❑N—❑Rap.1, H.P. DEPTH PUMP SET FF. FIRST WATER LEVEL <br /> ITYPE OF PUMP) <br /> ❑.OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ Oe..L BORING y ss <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING <br /> ❑PUBUCRMUNICIPAL ,❑1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> �❑ <br /> IRRIGATION/AG LTJ OTHER 3 a , GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> LTJ MONITORING /^ GROUT SEAL PUMPED:❑Yr ❑Ne CONCRETE PEDESTAL BY DNLLER:❑Y- [IN. <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE /` <br /> PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Gee 1-6C <br /> 1 HEeEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES A <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHI <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIF <br /> THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCEOF_THE WOPK.FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS <br /> CALIFORNIA.' THE APPLICANTUST CA!!2I/HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(206)406423.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> n <br /> SI—d X l— f_ 0nus.( :°�C✓�7/J/7_( /Z74/7041G/' Do. <br /> �� <br /> PLOT PLAN(D—to r-1.)Se.l• 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.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 /> �4C <br /> h <br /> DEPARTMENT USE ONLY <br /> Appli-1—A..a'.d By D.t. A— <br /> Grout I-p-tlon By - D.te Pump I—P-tion By ) I�Z-oo <br /> D.b <br /> De.—don In.pxtlon By D.t.i3U <br /> C.—I.: WOOW A-0/t463 -6404 15i} 21�L�rJ E (46-0 PyMcc� w� Gtr I7�i`F �W�°t <br /> ` ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />