Laserfiche WebLink
APPLICATION FOR WELLJPUMP PERMIT <br /> jAN JOA(2UIN COUNTY PUBLIC HEALTH SERVi__ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 <br /> 1209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete IB Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLIGATtON IS MADE IN COMPLIANCE WITH SAN <br /> 4 JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESWOR APN# 0111AJU - CITY_ 1 ir`1 C PARCEL SIZE/APN# <br />+ OWNER'S NAME ADDRESS__� �_ PHONE# <br />� - y <br /> CONTRACTOR ADDRESS xuC# PHONE* <br /> SUB CONTRACTOR -41 ZA ADDRESS LIC# PHONE# <br /> TYPE OF WElL1PUMP: 13 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 13 OTHER <br /> 1 13 INSTALLATION IELL SY`s7 EM REPAIR © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> I A ❑New❑Repair H.P. DEPTH PUMP SETLLFT. FIRST WATER LEVEL _,_,,,,, O <br /> (TYPE OF PUMP) <br /> A ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL It ❑ SOIL BORING 8 <br /> j DESTRUCTION: <br /> INTENOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> '00DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE Of CASINGISTEEUPVC DIA.OF WELL CASING D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R C <br /> ❑ IRRIGATIONIAG ❑OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME E" <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S l <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONMRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER �I <br /> F <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 S <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ` <br /> THE FOLLOWING:.-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF-4 <br /> CALIFORNIA CANT NtWK CALL 24 HOURS IN ADVANCE FOR ALL REWIRED INS TIONS AT 1309)4693423. COMPLETE DRAWING AT LOWER AREA VIDE V <br /> Signed X S' � ,.. Title <br /> TT 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 PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> - -- - <br /> ............. ., .. <br /> ! _ ., -- <br /> .. <. -. -,.. .., .. .. ... .. ., ., <br /> i., <br /> . ... .. :.. <br /> � . <br /> ,...... <br /> .. <br /> t <br /> . .....:...... .. <br /> ...! . - .. <br />` DEPARTMENT USE ONLY <br /> Application Accepted By L... „+ -� Date ! Araa ' �1 <br /> Grout Inspection By o Date - Pump Inspection By Date <br /> i <br /> Destruetion inspection By Date <br /> Comments: ' <br /> 1 <br /> f ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AUNT REMITTED C EC (CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />