SU0007408 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLlPUMP PERMIT ` 3AN JOAQUIN COUNTY PUBLIC HEALTH SERV. ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.368 i (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE rHAPTER 9-1115.3 AND THE STANDARDS F S N JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSlORAPN# CITY l3 _ ,PARCEL SIZEIAPNM OWNER'S NAME ADDRESS PHONE* w CONTRACTOR Ca u+"��' ADDRESS LIC#-� F4ONE if SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLlPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER %VINSTALLATION 13 WELL SYSTEM REPAIR [ICROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL# (t i WN.ElRepair H.P. DEPTH PUMP SETJaFT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ S {{{�``` DUI-or-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING �- ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D �OMESTICMRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGlSTEELIPVC DIA.OF WELL CASING D ' v ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R j ❑ iRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E " ❑ MONITORING GROUT SEAL PUMPED: ❑Yee 13No CONCRETE PEDESTAL SY DRILLER:❑Yes [IN. S 1 S I� APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE - PROPOSED CONSTRtiCT10N1DWWAUGER CABLEN6 METHOD: MUD ROTARY AIR OTHER �C•.; I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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 FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Title QJ� Date — ~, i Sipnsd% - - PLOT PLAN{Draw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL.SYSTEMS. 3. DIMENSIONED OUTLINES 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 PROPERTY OR ADJOINING PROPERTY. .. .. ;.. a .. ........... :. - ..,...:... .., - -- -,. .. -. .. .. .. .. .,.... -.-. _ .. .. _ -- - - TY �tf De ri � - .. .,..,..... ... .. .. .. 13r Ill .�]ilr _ - 1 r1l �i ui .x _ _.: .... _ t. _ DEPARTMENT USE ONLY Application Accepted By Date Aree�,,,Z ' Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date ' d Comments: rva ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUM89t INVOICE 0 D �2D a D q-7 5a '