FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT �! AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ) PAYMENT ENVIRONMENTAL HEALTH DIVISION 11 " ` RECEIVED ' P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 `s _ 4(' 1209) 468.3420 i ',I 7 .�9 SAN JOAQUIP,; Cri�J�-,ITY NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUIJ-M HEALTH, tiERVICCS (Complete in Triplicate) ; ENVIRONMENTAL HEAL T H DIVISION { Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and thel[Standards of San Joaquin County Public Health Services, Environmental Health Division. l Job Address/or APN# 1Gf-� Y�►pr lee uoy kic A-b CityS"00tlf.T-1c,f -1 Parcel Size/APN# i owner's Name VA wl 6 2A4VA Addressco Ih f L '. zo.tJl Phone # 98Q Contractor/1— C, +-f OA A-rl O^-I Address 4 J$J l f Grp rL D Rd 4`! L i c#137 T 7-2i Phone #�C_1,1_3 112- o o t k Sub Contractor Address i Lic# Phone # 5C44- 4041 pied TYPE OF WELL/PUMP: [I NEW WELL [I REPLACEMENT WELL [I MONITORING'WELL #. 0 OTHER 0 DESTRUCTION 13 OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # X SOIL BORING [1 INSTALLATION 0 WELL SYSTEM REPAIR [I CROSS-CONNECT REPyAyIR 0 VAPOR EXTRACTION WELL # 0 New [] Repair H.P. DEPTH PUMP SET !I FT. FIRST WATER LEVEL (TYPE OF PUMP) i !C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS E [I INDUSTRIAL [1 OPEN BOTTOM DIA. OF WELL EXCAVATION l DIA. OF CONDUCTOR CASING [I DOMESTIC/PRIVATE E] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC �I k DIA. Of WELL CASING [] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL__ra TOTAL SPECIFICATION } [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME /K MONITORING /` GROUT SEAL PUMPED: A Yes 0 No I� CONCRETE PEDESTAL BY DRILLER: [1 Yes [1 No APPROX.DEPTH 6 f Fe LOCKING CHESTER BOX/STOVE PIPES E PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE OTHER_ 1 I hereby certify that I have prepared this application and that the work will be done inkaccordance 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, 1 sha[Il not e.ploy persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance of the work for which this permit is issued, 1 shall empEoy persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT 1 MUST CALL 24 HOURS N ADVANrFOR� EOUIRED INSPECTIONS AT(209}488.3423. Complete drawing at tower area provided.Signed X Title) itOT4-Fc- �'*"1ACt /� Dateg PLOT PLAN (Draw to Scale) Scale ! to Y r 1. Names of streets or roads nearest to or bounding the property.~ 4. Location of house sewage disposal system or 2. outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property, and walks. pI II U ;t I IT C> F! 1J A iA �— -r P n 10M . O Sv if � I` +9 S DEPARTMENT USE ONLY Application Accepted By!�2� Date. � Area?Ib01 Grout Inspection By Date Pump Inspectipn By Date it F Destruction Inspection By Date Comments:. 'h 4 'p ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE IE if II �r � I