FIELD DOCUMENTS FILE 2 - Laserfiche WebLink

Home Browse Search

I PP toPLICATION FOR WEWPUMP PERM' S . ' OAQUIN COUNTY PUBLIC HEALTH S .:,ES ENVIRONMENTAL HEALTH DIVISION---', 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete III Triplicate) APPLICATION 18 HESE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUM COUNTY DEVELOPMENT TILE CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. Joe ADOIEOOION".-611 r V Q�/ t5 1 M!.�•� crrr S 1 6 C('� )O V\ PARCEL SIZElAPN1 1� r v�I'LI�-l^ owaor..Aaw W'-S t C-14-4 PrO ff -P f L& 5 ADDRESS P.a Bo x 6 1 5' loc�10 In Q PHONE t f 4 f5-0 3o;• coNTEtACTDIt d VO�I�'�Q V*d EKa}roti *.--N,lq ADDRESS N 00! k/• Wi l ftM WM 1/I S 19LIC' 0 0 1 PHaNE/ L47- l`�lbl/ 0 ca#rwACTotL Jr�I?►t U4��v�/ ��i kQ ADDRESS ucs 6545 764 aU PHONE r TM Or w81R-saft Is Mw w4em ❑ REPLACEMENT WELL ya MONT ORING WELL/ 61 71 ❑ OTHER ❑ MOTAUATK„/ ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑PI.-❑ft.,r, H,P, DEPTH PUMP SET FT. FIRST WATER LEVEL O RYrE or FUNIM ❑ OUT-OF-SERVICE WELL ❑ OEORHVSICAL WELL# ❑ 60IL BOPoNO 9 ❑twurr"ICTEON: i TYP[OF WELL CONSTRVC7ION SPECIFICATIONS n A ❑ OptltFlBAL o❑OPEN BOTTOM DIA.OF WELL EXCAVATION I 0 DIA.OF CONDUCTOR CASING .1 J O F,g':`.�vy 13ppL�BIECJRVAT[ 1�7R ORAVEL PACXMZE 3 TYPE OF CASING/STEEL/PVC [P it�- Df A.OF WELL CASING ♦/ O �.' U /URicamupw7AL ❑O/BVEN DEPTH OF GROUT SEAL 7 SPECIFICATION SCA . HO R ❑ /O111OATI10MAO ❑OTHM GROUT SEAL INSTALLED BY GROUT BRAND NAME POP 1 Ie kd E ® mom. N,N / GROUT SEAL PUMPED: ❑Vee I�Ne CONCRETE PEDESTAL BV DRILLER:❑Y• ®Ne S Arpmx OwtN S LOCKING CHESTER BOX/STOVE RPE 5 PFA O�CONSTIRICTION/DAILUM M@TNOD-. MUD ROTARY AIR ROTARY AUGER CABLE OTHER - 1 WeIEW CGFMFY THAT 1 HAVE~AHED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND I<OUI ATI0N0 OF THE"A JOARRt COUNTY. 140ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 't CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TIM PEPMfT KROLIM.1 BNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOtLOVVWM; '1 CERTfY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 188UED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIORSA.' TEE AP/PLLWAN/T/LMUOj CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT 120011'441SJ422. COMPIXTE DRAWING AT LOWER AREA PROVIDED. PLOT P�J elpw/X /� /i/t�-!Rf/►� Tlt1e S P L4 10 Y 5 I Q�l �j L'a�D Q I S � On• y ��L 71 PLOT PLAN IDrew to Soelel Salve 1. NAMED OF STRAMS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 048POSAL SYSTEM OR PROPOSED 2. OUTUNIF OF THE PROPERTY,GPV01O DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DOwENSIO ED OUTUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRI/CTUM9.INCLUDINO COVOWD AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ....-.... �.....i.. ......... .. .. ..:..................... ......... .... ........ _....-..... .. .. ........ .. .....i. ..... .. ... .. .. .. .. 1 - i bt/Ia:r K I Q Irk (Z--OV- MMBI �j�yTT WE ONLY APWIa.rlen Aaveered Be i V (/�(� �" -- ONe 1 Mr Trow Impeerle..Br / e Mrepeetlorr BY Z- Date- ACCOUNTING ONLY: AID# FACT PE CODE@ FEE INFO AMOUNT RETMTTED CHECK#ICMH REcipp D BY DATE PERNITISEPMCE REQUEST NUMBER INVOICE Pub.Health Serv.-Em/iro.173(1I97)