Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> G NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CempMu In TrIpDcalal <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1 115.3 AND T E STANDARDS OF BAN JOAQUIN COUNTY 711L" IEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN1 ( � [ c �� pL CIPARCEL 91 / R'N/ <br /> OWNER'S NAMED7Zp <br /> 1 / � 1 l �������/ �✓ Yl Qii�o! p EI <br /> CONTRACTOR �',�G� ADOREee�y7 // ✓� ti� UC(�yo PHONE I — <br /> SUB CONTRACTOR ADDRESS UC/ MIONE <br /> TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTOFYNG WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRIOSSLONNECT REPAIR Cl VAPOR EXTRACTION WELL I J <br /> ❑New Rep.lt H.P./ � <br /> DEPTH PUMP 8ET . FIRST WATER LEVEL` / O <br /> (TYPE OF PVMPI <br /> ❑ OPT-OF-SERVICE WELL ❑ OEOP/IYSICAL WELL I ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> 34 DOMESTICPPRIVATE Cl GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO O <br /> ❑ PU13UCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING / ! GROUT SEAL PUMPED: ❑Y.. [INoCONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S <br /> APPROX.DEPTH [ / LOCKING CHESTER BOX/STOVE APE 5 <br /> PROPOSED CONSTAU CTION/DRBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT I I4AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR RL)"ONTRACTIIG SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT N THE PERF0,09ANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SVBJECT TO WOAKMAN'S COMPEN ATION LAWS OF <br /> CAUFORHIA C NT MUST CALL 21 1 DVANCE FOR ALL REOUIREO INSPSCT10NNSHAT 12061 409-S423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 8lpned X Tltl. �/ Y S Da• <br /> PLOT PLAN 0—to So.l.l Be.l. to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OINONO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLNTS AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTINN RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> : g.... ,.. :.. ........ <br /> 75 <br /> ...... .... ... . . . <br /> ..... ..... ; . .. . ... . ..... 3 199 <br /> DEC <br /> :. .. <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DEPARTMENT USE ONLY /G� <br /> Appll..tlon Amepted BY L� D.te ' `� A," <br /> GroU Impeelbn 0r D.ts Pimp Irnpeotlon By D.1• <br /> Dnrbuetlen I—peotlon By Dae <br /> C omme.�t c <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CIIEC ASH RECEIVED By DATE PETONIT/SERVICE REQUEST NUMBER INVOICE <br /> 3 Z> ogo I Sp- OU -4 1 -5 LAI�l30 l S � <br />