FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

qw APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 RON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Campkl@ M TrlpRe$ul APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMMA INSTALL THE WOR(DESCRIBED.7III9 APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVEL/OjP�1MIE�NTL,,TTTLE,CHAPTER 8-117115.3 AND TTHHE`STANDARDS OF SAN JOAOUIN COUUNNTY PUBLIC HFALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESB/OR AM$ I`Nry,(1 JIM�IUA'. fX.EX11(A,I��KA Off-I CITY 1 PARCEL BIZE/APNI OWNER'S NAME IAT:iPN`=D 111Yrt1tiu)iwY RP�)13'1 We3F IDDP.WI ADDRESS_CLVIsjyftA�'{5..D(1 RHONE I� AOOPEBS IC73M old (z((•T�lllle, UCA MON.E 2— CONTRACTOR 1�[+�Ell[1.Y7 IY\k�l'NLt�OW& BUB CONTRACTORGI�..A 1/(1I�1Y�I ADDRESS g5C,HOWC 14VE, Nrh MI �Ml 4% MORE IJl0' 1� ' WLR TYPE OF WELUPIIMP xNEW WEUlS') ❑ REPLACEMENT WELL �MONRORINO WELL#JL .��❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑New❑Re.Nr H.P— DEPTH PUMP SET R. FIRST WATER LEVEL O HYPE OF PUMPI ❑ OUT-0F SERVICE WELL ❑ GEOPHYSICAL WELL F ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I,R LI A ❑ INUMTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A�/PLN�{LlM, hL,J//^`Z DIA.OF CONDUCTOR CASINO D ❑ OOMESTICNRIVATE XGRAVEL PACKBIZE TYPE OF CASINO/STEE ,a.fl140 TT N(L DIA.OF WELL CASINO D ❑ PUBM MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S ❑ IRRIGATION/AU ❑OTHER GROUT SEAL INSTALLED�p- GROUT BRAND NAME E XMOMTORING GROUT BEAT PUMPED:Xy.Vr ❑Na CONCRETE RDESTAL BY DRILLER:Ely. ❑Ne 5 APPROX.DER" lcX�Z IYAC11PL3� LOCIKINO CHESTER BOXRTOVE PPE S PROPOSED CONSTRUCTION/ Mlmo METHOD: MUD ROTARY AIR ROTARYAMERCABLE OTHER I HEREBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AWF RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWYNO:•1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMR IB ISSUED,I SHALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRNO OR SU"ONTRACTNO SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT N THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSON"""ECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- TILE C T CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSMMM$AT IZ/0//�if�.�4"- 122. COMPLETE DRAWING AT LOWER AREA P ADED.i Ba,,.a% oa'— '^ / T1I1.�a,4 �v Y I v,^� - D.K. 3—I — Fri PLOT FUM ID.ew 1.B.N.I%*I. •to 1. NAME@ OF STREETS OR ROADS REAREBT TO OR BOUNDING THE MDPFRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSA SYSTEM OR PIOFOSEO Z. OUTLINE OF THE PTIOPERTY,ORAHO DIMENSION@ AND NORTH DIRECTION. EXPANSION OF SEWAGE DISFO IA SYSTEMS. S. DIMENSIONED OUTLINE$ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADII,$OF ONE HUNDRED FIFTY P. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING MOFEHTY. w I' URo410N OF rCW i m Ise sm Lm 1 Lin 151. Lm 15" Lh?ISq�1 Lm lb(P_> See,.l{� llecQ.