Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 96201-388 <br /> 12091 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. DJ <br /> Job Address/orr/APN# o?My KGIS.Snn /lLY' ���/� /'/Cit-y/ / /� / Parcel S/ize/APN# <br /> Owner's Name/1Fr�G /l��/1'lQ- Adores s1050 /,J�de/a/// ///)fC(/Y� (�, /D7(O1 Phone # 9b9 99-77-gS�9z- <br /> Contractor /��[/�[L7� 0r;1�%1K1 -��/ Address��L/l�y /���11r�_ Lic# �� Phone # - / /3� <br /> Sub Contractor \ / Address GA-' 953 C4 Phone # <br /> TYPE OF WELL/PUMP: ET� NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br /> H DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> [] New [) Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL `[I OPEN BOTTOM y T DIA. OF WELL EXCAVATION .20 //✓ DIA. OF CONDUCTOR CASING � <br /> DOMESTIC �IR id GRAVEL PACK/SIZE /��/� TYPE OF CASING/STEEL/PVC P1 6 DIA. OF WELL CASING /.t //IG/L� <br /> PUBLIC/MUNICIPAL /[I` DRIVEN DEPTH Of GROUT SEALlQQ4ESPECIFICATION <br /> IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY/ <br /> GROUT BRAND NAME ` / <br /> IT MONITORING �'" I ; GROUT SEAL PUMPED: p/Yes ❑ No CONCRETE PEDESTAL BY DRILLER: [I Yes pT No <br /> APPROX. DEPTH �( �U LOCKING CHESTER BOX/STOVE PIPE / ` <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordinances <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the fol Lowing: I <br /> certify that in the performance of the work for which this permit is issued, I shall not e;ryloy persons subject to WORKMAN'S COMPENSATIONO <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the foLlowing: TO I certify that in the performanc <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of CaLifornia." THEAPPLICANT� <br /> MUST CALL 14-LIUUILS 111 ADV�FOR ALL REQUIRED INSPECTIONS AT (2091458-3423. Complete drawing at lower area provided. <br /> % Title 5't�ci. <br /> Signed / �Jr• Date <br /> PLOT PLAN (Draw to Scale) Scale " to —� <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> Gtr <br /> III AA <br /> C/ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> /p q Date "11f � Area'-( > <br /> Grout Inspection By -= 'ti`'"`"�'r-� ' Dates ��,� 15 Pump Inspection By Date <br /> Destruction Inspection By Date Comments: �LQ(] J /07 L/Q U/ <br /> 0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ECN CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 4 1 U <br />