FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATIONPR QLLIPUMP PERMIT I / 'SAN JOAOUlh560TY PUBLIC HEALTH SERVWI ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 (209) 488.3420 TH 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN 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 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ] JOB ADDRESS/OR APN+T `1k 876 Country Club Blvd. ,-, CmY Stockton, PARCEL SIZEIAp'Ni2��1c,]-191-01 OWNER'S NAME ��trt+tMcl"+�.r,ITI & Mrs.Tt,7Mannuel Sanchez _ ADDRESS 1633 Wuinut Street West PHONE. (�) 464-�1p291 j CONTRACTOR tNEJ�L�t�ty M�-EM lv MS ADDRESS 1� E. Bamer �reet UCX �]1�CTl! PHONE I ULK=S300; WMWAM DR= r�Y11 ,c SUBCONTRACTOR w- ADDRESS X'3_36_ R3_Q V]_.tira_LFC/ C57 710074RIDNEr X707) 37_1643� r TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLN ❑ OTHER ' ❑)NSTALLATiON ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I Jr t ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 6 , fIYPE OF PUMP) ! � 1 ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL• 10 SOIL BORING with collecticn g. 13 DESTRUCTION: of Later . les by hT d pxmch I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING A- { ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKIStZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ! ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ® MONITORING II II F GROUT SEAL PUMPED: 1:1 Y. ❑ ea ❑Na CONCRETE PEDESTAL BY DRILLER:❑YNo St APPROX.DEPTH `to 1 4'- LOCKING CHESTER BOXISTOVE PIPE 4 S: sI PROPOSED CONSTRLJCTIONIIMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY 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 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,I 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 I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE:A7T C 24 HOURS IN ADVANCE FOR ALL REOIARED INSPECTIOr,NNSSj�A�T 1205!468-9423. COMPLETE DRAWING AT LOWER AREA PROVIDE Slpr�ed X Title �_! Date __- PLOT PLAN(Draw to Scale)Scale 'to R 1. 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 6. 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. - -.. f .. .. ......... ...,..... .. .. .. - l - .. .......... . . ................. . ., .. .. _ ............ - - ... ..... •.f.. ....:.. ..... ...--- .........:.......:... -..............;.....-...-................-. .. .. - ....... .. -- j ........... ................. ....... ... ................ ....... .. ............ ............ ..... ........... . ..... ....... ........ . . . ........... ............. .......... ...... ........................ ....... DEPARTMENT USE ONLY �•��C� �� (3 Applleatlon Accepted By I' Date Area f 1 Grout Inspection Hy 1I Date Pump Inspection By Date S pmtructien Iro4pection By Date t Commerns: _ } ,,4 , ACCOUNTING ONLY: d AID# it FAC# .I .J PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY GATE PERMITISOVACE REQUEST NUMBER INVOICE n f sem,. I