SU0004792 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT — vAN JOAQUIN COUNTY PUBLIC HEALTH SERVi—.,- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 408.3420 MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICampl&U In TFbACIIS) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PIBLIC EALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. 1 �% JOB ADDRESSMR APNNI\I G_ X411 /� ✓1 CITY!/ /, s't .L/ �PARCEEL gIZE/APIJ ly l�l / �/'L9C OWNER'8 NAME Inc, L�La I I C an, I ADDRESS,:?4w LG / 'ZS // L f �I L��V10NE fek/ CONTRACTOR //c SGI ILS 1',L I(L\s _LI'Tc ADDRESS 11 1 /Y/UPfJ UCiZ�l Z PHONE IS�>Z SUB ICJ PHONE I TYPE OF WELVPIMP: EjgNWV WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ New ❑ Rallr H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL O RYPE OF PUMP) ❑ OUT -0F -SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING .*PROPOSED ❑ DESTRUCTION: 5 1997 <O J 'T INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& �iL1 ❑ PE COD" INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO pJ ��❑'LF ❑ DOMESTIC/PPBVATE CE3:QNAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASINO D ❑ PUBLICRMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION goon �RIGATION/AG ❑ OTHER GROUT SEAL INSTALLED- GROUT BRAND NAME LL ( E> ❑ MONITORING Cal. GROUT SEAL PUMPED:l1'" [IN. CONCRETE PEDESTAL BV.U]RILLER: ❑ Y. Oy S•-1. f� / 0 413 5 APPROX. DEPTH. LOCKING CHESTER BOXIBTOVE PPE S.4- gooSEP .*PROPOSED PROPOSEDCONSTRUCTION/ UJNO METHOD: MUD ROTARY ✓C AIR ROTARY AUGER CABLE OTHER 5 1997 <O J I HEREBY CERTIFY THAT I HAVE PREPARED THIS APR.ICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 IB IBBUED, I SHALL NOT EMPLOY PER80NB SUBJECT TO WORKMAN'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 IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP *AT10N LAWS of CAUFORNIA..'' THE ARUaIUT M�US//TEDC.A`LL/p4 HOURS IN ADVANCE FOR ALL REQUIRED 11416 TIOHO AT (]061 444 422. COMPETE DRAWING AT LOWER AREA PROVIDED. _.. FNVIHbNMENTtA HFAI TH DIVISION SIgro X J/ (TL /I/EY ✓C.L i�KI THIS �,A I(llev� D.I. POT PAN (0— 10 Sp.Ie) bull m 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE FAOPRTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PfKIMSED 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. Appllalllpn Af..Ie Gmul Irnpallon Dslruetlon Impaaen DEPARTMENT USE ONLY Pump Impatlon DSts � 77 Ar. 2–/1 ACCOUNTING ONLY: AIDS /nV PE COD" FEE INFO AMOUNT REMITTED HECK CASH I DATE PURMITISERVICE REQUEST NUMBER INVOICE goon G'It ayP Al�; ")g L% 35� 3 0 413 5 gooSEP PAYMENT m aax� � 5 1997 L�n�( SAN JUAUUIN GOUNfY PUBLIC HEALTH SERVICES l _.. FNVIHbNMENTtA HFAI TH DIVISION Appllalllpn Af..Ie Gmul Irnpallon Dslruetlon Impaaen DEPARTMENT USE ONLY Pump Impatlon DSts � 77 Ar. 2–/1 ACCOUNTING ONLY: AIDS FACT PE COD" FEE INFO AMOUNT REMITTED HECK CASH RECEIVED BY DATE PURMITISERVICE REQUEST NUMBER INVOICE G'It ayP L% 35� 3 0 413 5