FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR INELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q DENVIRONMENTAL HEALTH DIVISION AUG _ 8 ,O, BOX 38B, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripOexte) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND[On INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT, 1TITLIE,` M- pCHAPTER 9-11115.31 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICO HEALT1H SERVICU% ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI � nil LJ, E re l CIT/ �1 L7`' jS 17]N PARCEL SIZE/APNI OWNER'S NAME Q`��1 IQL l JI�CAJ`VL C��_ 1 1CIy ADDRESS ` �M/419M PHONE P Z CONTRACTOR ADDREs6yJ Izecoflu LICPPHONE 7�! T20 SUBCONTRACTOR AMMAR LicitQ(� PHONE / TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL h/IONITORINO WELL • ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO99-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL a ❑ New ❑ Repair N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-OF6ERVICE WELL ❑ GEOPHYSICAL WELL I X6oIL 00mNG _C:5z R ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION 6PECIFICATIONS N ^ A ❑ INDUSTRIAL ❑ OPENBOTTOM DIA. OF WELL EXCAVATION 2 DIA. OF CONDUCTOR CASINO AI'T C 1 ❑ DOMESTICIPIVATE ❑ G VEL PACKISIZE TYPE OF CASING1UEEUPVC % eFVCd DIA. OF WELL CASINO 1� /L_. O ❑ PUBLICIMUNICIPAL DRIVEN DEPTH OF FRONT SEAL Jr SPECIFICATION IA/ .S/rJ A ❑ IRRIGATIONIAO ❑ OTHER FRONT SEAL INSTALLEDr,�SYTRef1JIC[, GROUT BRAND NAME E MONITORING I� ( GROUT SFAL PUMPEO: Alyea [] NO CONCRETE PEDESTAL BY DRILLER: ❑ Yin Ne S APPROX. DEPTH �J LOCKING CHESIEn ROXIRTOVE PIPE S PIOPOGED CON11TRUCTIONIDIIWNG METHOD: MUD ROTARY Ain ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE.WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE "WWS", AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNEn OR LICENSED AnENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OFTHE WOW FOR WHICH THIS PERMIT 19 ISSUED, I BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN4ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: • I CERTIFY T TIN THE P iF0 MANCE OF THE WOW FOR WHICH THIS PERMIT I6 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORID.LAN't COMPENSATION LAWS OF CALIFORNIA.• T{I ANT T CALL HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914811 12G, COMPLETE DRAWING AT LOWER AREA PROVIDED. SI0ne8 x TIUa $4 1 big �( ��S7 - Data 9 PLOT PLAN Inrew to Sawa) Scale ' to 1 . NAME OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMB. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOnEO FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAIJ B. ON THE PROPERTY OR ADJOINING PROPERTY. u _ °.._ : . .. .:.. . . NTS_. .........:. ... .: .. .. C DEPARTMENT USE ONLY Applleellpn AcaepleA By `/^L// q�,aQ� Grow Ina Z Onle (NL/ Li Arae �� / P�nan ev '/.. v.� J Dae MP In.p«nan By--, Oae Da.e,kGen ImPeanan By Data Cemmarae: ejm&: p Gc� m 9 t[J g 01 ACCOUNTING ONLY: AID( FACS PE COD" FEE INFO AMOUNT REMITTED CNECP MASH RECEIVED BY DATE PERMIT[IERVICE REQUEST NUMBER INVOICE 3501 Q 1 00 1256 r oa S 0 I Pub. Health SAN. - Enviro. 173 (3/96)