FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT" _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV" I�3 4 ENVIRONMENTAL HEALTH DIVISION p 0 BOX 388, 445 N. SAN JOAQUIN S% STOCKTON, CA 95201.388, AUG 1 1995 '12091 48&3420 { I NON.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENCTTA'L'HEcA"LTH j (Complain IS TrVfiunl Wd�yl/y a-E&AMANCE WITH SAN Appl1CATION IB HERE BY MADE TO THE SRN JOAQUIN COUNTY MR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE W01K DESCRIBED.THIS Y?/L JOAQUIN COUNTY DEVELOPMENT TITM CHAPTER 9-1115``.3 AND/THE STAND AIIDS OF SAN JOAQUIN COUNTY PUBLLC HEALTH SERV/IC�E6.LE,�NVIFW/NFA PARCEL HRRAEILATPLH�1��SIO�' JOB gODRESSA)P APNd/� S/PI'17 ] JD7Q- 91 SV IV /JL�nn�TOIli S/u/�J�1(l�/�� C®i1 �/,x I /� /�I lL L1/$1O L` .EMNEI R / !I O..n,,/...;lz /M/, (D.J�! K/L rAwREsa L ^ pper�'' o �y OWNER'S NAME / �&0440? ` R10NE, /J�-� o _/ .� Is7c Aom "3uxIVhL&-"mQ �7/ CONTRACTOR 1 .`/.[,s't'UCl PHONE! N� S (7✓yM ADDREB 54---14 D — SUB CONTRAOTOB S'hv. :F , ❑ OTHER TYPEOFWELL/RIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONROPoNG WELLS J ❑ INSTALLATION 13 WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR [3 VAPOR E%TMCTON}WL" WELL/ O ❑N.❑R i, H.P. DEPTH PUMP Bi FIRST WATER LEVEL I ITYPE OF PUMPI ❑ OUT-0F-SERVICE WELL q [3 GEOPHYSICAL WELL, [3 SOIL BONING �f B 1 OESTPoICTION: 3 /- %A)L92 C !✓[%/s, M w l4 NJFV2y M IV 3 INTENDm UfE TYPE OF W ELL CONSTRUCTION SMIRCATI NS A ❑ INDUSTPoK ❑OFEN BOTTOM DIA.OF WELL EXCAVATION DA.OF CONDUCTOR CABINS D ❑ OOMEETICRRIVATE ❑GNAVEL PACKISQE TYPE OF CASINO/STEEL?C DIA.OF WELL CASINO I - J/ D ( ❑ RIBUCWUNICIPAL ❑DRIVEN DEPTH OF GOUT SEAL SPECIFICATION '!I!PVA. R [3tPoOGAmowAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME If E . MONITORING / GROUT SEK PUMPED: ❑Yr ❑Ne CONCRETE PEDESTALBVI DRILLER:❑Ys 13w APFROX.OEVTH Mu//';ylN�W3 'a1 LOCXINO CHESTER BOXISTOVE PIPE S PROPOSED CONSMMMON/ WNO METHOD: MUD ROTARY AIR ROTARY AUGER CARIE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APRJCATION AND THAT THE WORK WALL 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 FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WOROAAN'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 WALL EMPLOY PERSONS SUBJECT TO WORKMAN's COMPENSATION LAWS OF CAUFORNIA.' THE Ar4TIOANT MUST CALL 24 MOMS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 130914!411 2n. COMPLETE DRAWING AT LOWER AREA PROVE)ED. I / Awe // � '. &airo4X '�41��1 Title9'YU1'aL'/LL-L-�7EdIV;1.>!s1 Dart. � I PLOT PLAN IDrm Y to SeNel Seek'rosn II 1. NAMES OF BTREETB OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE MSFOSK SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE mBPOSA.SYSTEMS. 3. DIMENSIONED OWUNES 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 PIOPERTY OR ADJOINING PROPERTY. ®MWS � NW'Li. ... .: 1 STDG ASC. ... ,.. -. ......... AREA : ....:...,.. '. leSfcTn Sd -%eprrxlvc k s �18r `lvr 6vsJ)'('g� ae DEPARTMENT WE oxlr /y L-1APP6ttdI.fit tee By _ GraN Iropstlen BY Dae Pump Iropscl n BY Den,amn tIrolHalen Br Dae 1. 2 II q (a commsro: I ACCOUNTING ONLY: AID, FAC# ( PE CODES FEEIHFO AMODNTREMITYW CNEI,"X SH RWO,,,By DATE PRMT/SFRVICE REQUEST NIMBEq INVOICE I 35'0 3W) b D 005305 Wt4A, l (v f s