Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201 .388 <br /> (2091469-3420 <br /> ROR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complem in Tripli#atE) <br /> APPUCATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOO A PERMIT TO CONSTRUCT ANDION INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-111 $.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBUG HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNB CITY 45�Tnc'K 1LToa PARCEL SIZE/APNI <br /> } i Z� . <br /> OWNER'S NAME I U 1 ADDRESS 1. GI Y GF PHONE ,F 3L/I IO�II <br /> 1151,30 Gc 1 h i17 <br /> z4 <br /> CONTRACTOR 51Y1I FnLe!i' CQ ) IMA-t1 tai ADDRESS 1710 MCLIIII cdXailcp UCB RHONE 8 zcq <br /> 1it'3 (( OS <br /> SUBCONTRACTOR 5na � YrL� 1� M ZTwlo 'C�n -Tio ✓1 ADDRESS21s IQ VJCL fL6Cef4IUCN S1Zu8 PHONEY t-I4.S V�I <br /> TYPEOF WELLIPUMP: 4f1 NEW WELL ❑ REPLACEMENT WELL pL MONNORING WELL .I U.1 " f ❑ OTHEfl <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ♦ J <br /> ❑ Naw ❑ Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> 77M OF PUMPI [31 <br /> OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a tt A <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION /] DIA. OF CONDUCTOR CASING D <br /> ❑ DOMEE TIC/PNVATE GRAVEL PACK/SIZE j L _ TYPE OF CASING/STFEUPVC C"II�O. PLIC. DIA. OF WELL CASING Poe <br /> D <br /> ❑ NBUC/MUNICIPAL ❑yDRIVEN DEPTH OF GROUT SEAL a T-f SPECIFICATION ' 5ck L40 R <br /> ❑ IRRIGATION/AG 00 aTHGROUT SEAL PUMPED:ER GROUT SEAL INSTALLED BY GXGC.�CtYJ1M GROUT BRAND NAME E <br /> 0MONITORING „ (' ❑ Vs ❑ No J CONCRETE PEDESTAL BY DRILLFN ❑ Ys ❑ No S <br /> APPROX. DEPTH ICI r\ LOCKING CHESTER BOXISTOVE RPE IIiS S e <br /> PROPOSED CONSTRUCTIONIDW WNO METHOD: MUD ROTARY AIR ROTARY CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE GONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANO RULES AND M <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 't CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PEWIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUPOANIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA^THE APPLICANT MUST 7CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 130814410 4". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> $N. X.(" <br /> ` 1n i. nn NL . F'�r'Ny\I1.LL-.1 Tlne��Ud Zdc Q'? r L/ I SOr Date �5 9 . <br /> D ' to <br /> PLOT SONeI SUM_ <br /> 1. NAMES OF STREETS On ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 08 PROPOSED <br /> 3, OUTLINE OF THE PROPERTY, GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 /> else <br /> Af <br /> DEPARTMENT USE ONLY <br /> APplloetlon Accepted By <br /> Date Ars <br /> Grout Impaction By Date Pump Inapeptlon By Date <br /> Denowtlon Inpw/tioonn By <br /> IV 4 of Data <br /> Commmup: �C4V <br /> ACCOUNTING ONLY: AID# FAC# <br /> K CODES FEEINFO AMOUNTREMITTED CHECK#/CMH I McervErAy I DATE P6MIT/BFAVI REGU T INVOICE <br />