Laserfiche WebLink
APPLICATION FOR WELLJPUMP PERh - I <br /> SAN-JOAQUIN COUNTY PUBLIC HEALTH SErvw'ICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 p ump <br /> Q NON•REFUNDADIF PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I 60, .(J 6,t IComplets iB Triplieatol FTI�� <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESC 0.TI{9 A I IN COMPLIANCE WRI}SAN <br /> JOAQUIN COUNTY DEVELOPMENTTITLE,CHAPTER 8-1115.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SE E L H DIVISION. <br /> (' <br /> JOS ADDRESS/OR APNf 0 s t tR CITY –1 PARCEL SIZEIAPNE <br /> OWNER'S NAMEr ADDRESS PHONE f <br /> CONTRACTOR ADDRESS LICO27_ 2 PHONEZY 5`/ <br />`i SUB CONTRACTOR ADDRESS UCf PHONE# <br /> I <br /> TY_PEAF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MGNRORING WELL f ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SY EM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# j <br /> ❑Now RR".1, "'P. DEPTH PUMP SETJ T. FIRST WATER LEVEL <br /> (TYPE <br /> ❑ OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL SOMNO g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION@ A <br /> ❑ INDU9TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> 19 DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOI9TEELIPVC DIA.OF WELL CASING O <br /> ❑ PUSUCIMVNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRRIGATKTNIAG ❑OTHER GROUT SEAL INSTALLED SY GROUT BRAND NAME E <br /> ❑ MONITORING hk GROUT SEAL PUMPED: ❑Yes� ©Ns CONCRETE PEDESTAL 9Y DRILLER:❑Yes (IN. S <br /> f APPROX.DEPTH 0 :3,0---_ LOCKING CHESTER BOXISTOVE PIPE <br /> S � <br /> PROPOSED CONBTRUCTIONlWOLIING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9E9Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCE$,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TILE WORK POR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERBONS SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT TI{E ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPETIS TION LAWS OF <br /> CALIFORNI APPLICANT CALL 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12oa)41@-342!, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slgeed X Titler�? Gate . <br /> PLOT PLAN(brow is Best*]Scala 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OA BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR pROpO$ED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> a. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WR'HIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOININO PROPERTY. <br /> .,., ....,. .. - .. <br /> :. <br /> E <br /> f <br /> .. O� .. 1 . <br /> 4A`. .. <br /> :... . .. <br /> . :L,Fi�,gL.Ty <br /> r�,Ip� <br /> r 3 <br /> DEPARTMEMTUBEONLY ...-. - ,��/. C/.l�� ... ...-. <br /> Apprr.atlen Accepted By r Dot ✓ � I� Arss�� <br /> O.o.A 1"pecSon Sy O-ta Ptaep Inapeotlen Sy <br /> Date_ <br /> Deat,mlion Inepa 11—By Det. <br /> Commw.te: <br /> ACCOUNTING ONLY: AID# FAC# <br /> i <br /> PE CODES' FEE INFO AMOUNT REMITTED CHEC !CASH RECEIVED BY DATE POWITISERVICE REGUEBT NUMBER INVOICE <br /> O5u7 O-CX3 � t 315T ( ' <br /> Pub.Health Serv.-Enviro.173(1/87) <br />