FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

• APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplob In Trlplie@tal 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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# COOK ORD, S F P Q RELEASE SLTE CITY NO L l it c-A PARCEL 81ZE/APNI 1 /p OWNER'S NAME D S F PP LP. ADDRESS 1100TOW L UCCN ORA �p PHONE(7I4J56&"t0 CONTRACTOR (RCC LStO/J SAMPLI�1Cr, INC ADDRESS 1400 5.SOTk J4 RtgjMggjwc, (, 0F7 PHONE 1'v 237-' J�5 SUB CONTRACTOR L-e -1 ADDRESS LIC# PHONE# TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# V.OIL BORING CPT- 5 R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/StZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO O ❑ PUBUrC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL KOAA 1 V TO SI�ICI"/�CE SPECIFICATION N64T•C1 •E4'%W T R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BVNLLGROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: Vs ❑ ..r�p Ne 1 M1EM I V CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH 90 'rL�- LOCKING CHESTER BOX/STOVE PIPE T S PROPOSED CONSTRUCTION/DMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER C- P t HE9EBV CERTIFY THAT I 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSON@ SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING 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 APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED pnINSPTCTIONS AT 1"01 40*-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Bted X AG-ENT G-ENT rOK PL£CISIofJS�4mfLll/rT Date 9-24 -q9 ►lOT PLAN mraw to Baalel Bade 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. 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 RAOW8 OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SEE' 1n� RK LAW °t,�tiE� DEPARTMENT USE ONLY 9 Appllaatlen Amooted BY Date r-2- ` Arae C� 7's O—A Impeetton BY /Date P r p lnspeatlon By IGDate,1, q// Deatnretlen Impeelbn BY (�/ !' ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED C /CASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE 2501 7 — �ld AI ct Pub Health Serv.-Enviro.173(1/97)