FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SEL 4 p ENVIRONMENTAL HEALTH DIVISION Awa P 0 BOX 386, 446 N. SAN JOAQUIN ST., STOCKTON, CA 6201.388 (209) 469.3420 1(11 19 1995 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compkto In TripUcats) LNVIRONMENTAL ��HHCECALTH I APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIJ€IRRTIIS�ltPf+L�IL'AT10N IS MADE IN COMPIJANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1116.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. rv� JOB ADDRESSOR APNS -74 1`y w• 11411 I+N ST. CITY�g//`P%(-V PARCEL SIZE/APN# OWNER'SNAME FRANK/� COF_1L/HQ ADDRESB'4 ``1' \N' 114 STITAACY9539k� V35-Ml- P.O." 35—Z Z4 1. CONTRACTOR V W ❑t l(1-Ll 1y L7 ADDRESS P0"SI,R t o vI SrA(LA 9457��65848 b -+0-f1-44-7815 PHONES SUBCONTRACTOR ADDRESS J^2 UCI PHONE# TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL .rMONITORING WELL# It a-r'F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL l ❑New❑Repair H.P. DEPT"PUMP SET FT. FIRST WATER LEVEL- p (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLS ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 13 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION �'00// DIA.OF CONDUCTOR CASING NIn- D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC SCN -4D PVC DIA.OF WELL CASING Z,C)" D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 5 SPECIFICATION R E] IRRIGATION/AG ,OTHER GROUT SEAL INSTALLED BY V+W GRotrr BRAND NAME/JFJ�T C E=M EtJ trte• ® MONITORING GROUT SEAL PUMPED: MY. [IN. CONCRETE PEDESTAL BY DRILLER:❑Ym [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE_ S PROPOSED CONSTRUCTION/DIIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW$,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 WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEd THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OC CALIFORNIA.*,•T_HE,APPICAN. MUUFT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed x_ Ivy!/WC�yI 0-31DE1ARlF Crf� TitleObIST"-�C.�l-o(�IC7'tl-T1-CWt�ICS .Dn. �/(4 105s— PLOT PLAN(Draw to Solve)Scale ( •to 5o' t 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 S. 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. ST } ... ST Post-Ito Fax Note 7671 Date Z pages .... To From Co. Co./Dept. ... .. .... .... ... ..... : ...:._ Phone# Phone# - .. .... .. ..... O .. .: 50 ..... ._..... ' Fax# Fax# 538-�5BS . SCAR£ F�Er Z Q S' MW �.. U .:. low �v � MW=3 (��J� �� Application Accepted BY DEPARTMENT USE ONLY�F---IS.>`C Date�74///^ Area Grout Inspection By Date Pump Impaction 13 CCC Data i Dmtruetlon Inspection BY__ Date " 7 I Comments: ACCOUNTING ONLY: AIDS FAG! PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PMWIIT/SERVICE REQUEST NUMBER INVOICE