SU0004580 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT ��ee 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIU. ( - C, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPUCATKIN IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER`JR 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SSE�ROCES,ENVIRONMENTAL HEALTH DIVISION. _ JOB ADDRESSOR APNIF,Z-7 057 )w /C` _CITY///{ YIJu PARCEL SIZEIAPN# tI> OWNER'S NAME_ E�-F•/�,,1 y^•n°1^�,.'/�� ADDRE88 / S/�I7'C. RHONE��L,71 CONTRACTOR L1-1-1 \�W'y ADDRESS II o UCF_�77Jds RIONEI�� I- �� SUB CONTRACTOR ADDRESS LICA PHONE P TYPE OF WELVPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER /� ❑ NSTALLATION [:3 WELL fSYSTEM REPAIR [ICROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL a ✓ i V C ew❑Repair M.P. J DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF MMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL✓/ ❑ BOIL BORING B n ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 1❑/DfDUSTRIAL ❑ N BOTTOM DIA.OF WELL EXCAVATION � DIA.OF CONDUCTOR CASING ^ 0 DO DO MESTIG➢RIVATE �VEL PACK/SIZE TYPE OF LASING/STEEL/PVC DIA.OF WELL CASING n D Ti ❑ MBUC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL f —'Q SPECIFICATION -/FJ R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME fir_ E ElMONITORING / ORO SEAL PUMPED: . ❑N4 CONCRETE PEDESTAL BY CRULLER: V. El No 5 APPROX.DEPTH—1—J 0 LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTIONIDWRING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE__OTHER__ I HERESY 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN%COMPENSATION LAWS OF CAUFOMIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APP MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12")4ai3422. COMPETE DRAWING AT LOWER AREA PROVI ftX�y[/J, /g , �_(j Title PDT PLAN (DreW to S 18)SW4 to 1. NAMES OF STETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED RE 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. 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. x 3 I I 1C I i MEN C� SSP - 8 1995 \ cNVU{ONkjeN ..ff1S$RVi r MENtAL HEAL7H CEI5,I,,I G� II S li