Laserfiche WebLink
(~ APPLICATium rUN wt1.14100100 PERMIT <br /> ` .,AN JOAOUIN COUNTY PUBLIC HEALTH SERVICE <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 85201-358 <br /> (209) 4883420 <br /> ' NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ICemPhts in Trlpfluts) <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 9-1915.3 and th Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# <br /> City C� P rcel Size/APN# <br /> Owners Name Address 7 ^ <br /> Phone # <br /> Contractor Address Lic# 0- <br /> ` Phone <br /> Sub Contractor Address Lic# <br /> Phone # <br /> TYPE OF WELL PUMP: 17 NEW WELL [7 REPLACEMENT WELL 11 MONITORING WELL # <br /> [) OTHER <br /> [7 DESTRUCTION [] OUT-OF-SERVICE WELL 17 GEOPHYSICAL WELL # 11 SOIL BORING <br /> It INSTALLATION 17 WELL SY TEM REPAIR 11 CROSS-CONNECT REPAIR [7 VAPOR EXTRACTION WILL # <br /> New 0Repair H.P. 1 DEPTH PUMP SET / O FT, FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> NT N EUS TYPE OF WEII CONSTRUCTION SPERIFICATIOIJS <br /> 0 INDUSTRIAL [7 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING_ <br /> 0 DOMESTIC/PRIVATE 17 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> 11 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [7 IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [] MONITORING GROUT SEAL PUMPED: [] Yes [] No CONCRETE PEDESTAL BY DRILLER: [] Yes 0 No 'cl� <br /> APPROX,DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDAILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER, <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San JoaquinCountyordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agents with <br /> certifies the following: nI <br /> certify that in the performance of the work for which this permit is issued, [ shall not employ persons subject to WORKMANfS COMPENSATION.0 <br /> Laws of California." Contractors hiring or sub-contracting signature certifies the following: certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California.N THEAPPLICANT <br /> MUST CALL 24 HOURS IN VANCE FOR All REO RED INSPECTIONS AT(204)488.3427. Complete drawing ng at lower area provided. <br /> 01 0 <br /> Signed X <br /> Title <br /> Date`s <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 sews a dis <br /> 2. Outline of the property, giving dimensions and North direction. 9 posal system or <br /> e <br /> 3. Dimensioned outlines and location of all existing and proposed 5. proposed expansion of sewage disposal systems. <br /> structures, including covered areas such as patios, driveways, <br /> of wells within radius of 15D ft. on <br /> and walks. property or adjoining pr rty. <br /> ii <br /> I <br /> gg11 ` Y <br /> f <br /> I <br /> SIJ <br /> DEPARTMENT USE ONLY <br /> .• .Y <br /> Application Accepted ey <br /> Date Area <br /> Grout Inspection By Date Pump Inspection By '� <br /> T �uL�Date - Y <br /> Destruction Inspection By Date _ Comments: <br /> ACCOUNTING ONLY: AID# <br /> _FAC# <br /> PE CODES FEE INFO AMOUNT REMfTTED CNEC CASH RECEIVED BY DATE PERMITISERVICE EQUESTNUMBER INVOICE <br /> D X050( <br /> .1 l <br />