Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> 60 SAN JOADUIN COUNTY PUBLIC HEALTH SERV( <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 448 N. SAN JOADUIN ST., STOCKTON, CA 96201388 <br /> 1209) 488.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION I6 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLJCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESSMRAPN9 1856 Field Avenue D,T, Stockton PARCEL SIZT(E'IA��PNY <br /> OWNER'S NAME James Mair ADDRESS511 Div. St. moP_l <br /> Cab1 . 711GNEE 95008 <br /> CONTRACTOR Woodward-Clyde ADDRESS 1.03RCL <br /> 70 Old P1rvJJDF' PHONES 9163680988 <br /> Sa ramento CA 95827 <br /> SUBCONTRACTOR Spectrum Exploration gage <br /> nn.,4 lz�UCrCI��PHONE, 209465871 <br /> +nnnn <br /> TYPE OF Ml-UPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS , ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J <br /> 11N.11 Rep.l, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> (TYPE OF POMP( <br /> ❑ <br /> OUT-0E-SERVICE WELL 13 GEOPHYSICAL MILL E ❑ SOIL BORING B <br /> AhESTRUCTION: EXistT nq Mnni i-nri ng Wol l � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMESTIC/PNVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELJPVC DIA.OF WELL CASING O <br /> ❑ RISUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑N. CONCRETE PEDESTAL BV DRILLFR:❑Yr ❑N. S <br /> A X.DEPTH LOCKING CHESTER SOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONADW RING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTMCTOR'S HINNG OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- T T WT C M gI�IS IN ADVANCE FOR ALL REGUNIED INNECTNDN$AT ON191488 1n. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> `j <br /> Bipmtl X � TT111. Geolo gist <br /> Bi Loskutcgt <br /> pLOT PLAN IDfnv to 8pNa1 6uM 'tp <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 0. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSKDNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 PTIOPERTY. <br /> .. .... +... .... <br /> See Attached Map <br /> .... .. .... <br /> PAXNtIEAFT <br /> :.. :... <br /> MAY 17 1995 <br /> SAN JOAQUIN COUNTY <br /> . !.... : .. ... ....L.. .. <br /> "'" PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DEPARTMENT USE ONLY <br /> AppllWlon Acc.twl By DM. �� Nr <br /> Grout Inpxtlon By Dns Pump lmp flon fl D.b <br /> Drtru ipn Inpoption By D.to <br /> Comm..: <br /> ACCOUNTING ONLY: AIDS FAC/ <br /> PE coon FEE INFO AMOUNT REMITTED ECC ASH Rocipylp BY DATES P ITISFRVICE REQUEST NUMBER INVOICE <br /> VjVV <br />