SITE HISTORY - Laserfiche WebLink

Home Browse Search

PAYMENT APPLICATION FOR WELL./PUMP PERMIT RECEIVED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AUG 18 1998 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SAN joaQulN ccCOUNTYPUBLIC HEALTH SERVICES N (209)468-3420 ON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED EfJUIRONMENTALHEALTH DIVI.SIt)N ICImpN11 M TIIpReaul i APPLICATION 19 HERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT"TITLE,CHAPTER 9.1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH D 3104. r JOS ADDRESWOR APN# I 'r •i-' -�- Y I ' 1 CITY 'y"Ym PARCEL SIZEMPN t OWNER'S NAME 1 ( Do. C ADDRESS L11. Q !-, PHONE# CONTRACTORfli i AZ la 12'1 fti LICI7�XM-CFIdNE(7D7) J, 255 SUB CONTRACTOR ohr- F ADDIIE88 UC# PHONE# " .TYPE OF WELLMUMP- ❑ NEW WELL-- . ,❑:REPLACEMENT WELL .:❑ MONITORING WELL 0 .a z-�__..❑ OTHER. _ ❑ INSTALLATION © WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# •r Jy ❑Mew©Reph DEPTH PUMP SET FT.. FIRST WATER LEVEL-- f1YPE OF PUMP) O y ❑ OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELLJ SOIL BORING _ 8 0 DESTRUCTION: I FNTENOEQ ViE TYPE OF WELL CONfTRIPC TION SPECIFICATIONS I ';- A © INDUSTRIAL ❑OPEN Bottom DIA.Of WELL EXCAVATION_ �`'�� DIA-of CONOUCTOR'CASING A 3 ❑ DOMESTICIPRIVATE ❑GRAVEL PACKMZE TYPE Of CASINGMTEEUPVC _Nf� p1A,OF WELL CASING p ❑ PUBLICAALIMCMAL 0 DRIVEN DEPTH OF GROUT SEAL S U 4e t::' SPECIFICATION R ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY.Ar �N41 L GROUT BRAND NAME e MONITORING GROUT SEAL PUMPED: 19 Y. I,7 Na �/ CONCRETE PEDESTAL BY DRILLER:©Yr ONe S APPROX.DEPTH :2LOCKING CHESTER BOX/STOVE HPE—/v�41f S i PROPOSED CONITRUCTIONLOWNG LLIMETHOD: MUD ROTARY AIR ROTARY AUGER CABLE - OTHERPIl�'r•'T i 1JiJ 1 HEAERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WroRK WALL Be DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 1 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOFIIIA.• CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORMAW8 COMPFTISATION LAWS OF CALIFORMA.' T MUIt CALL •HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS At 42091408-242*. COMPLETE DRAWING AT LOWER AREA PROMOED. y Stoned x TIB. e0n-V4, / Ag PLOT FLAN OD to BaMd Seel.S�� •is 1. NAMES OF RESTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUT,2. DIMENSIONHE ED OUTLINESHE AND MNO DI ALL E IX ENSIONS D NO H DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. AND PROPOSED I. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. -- „STRUCTURES.INCLUDING COVERED AREAS SUCH AS.PATIOS.DRIVEWAYS,AND WALKS. .- -_.... _ .ON THE PROPERTY OR ADJOIMNG PsopE TY. 140t U) . ........ 14.0 :. . ". :.. 77 0l5 --�-fP n ai.• ..aa - �.a.'.tet a .,,.:4'r.��.,,-.. F :.,:4_M1 :. EPiUUTMEN BE tlkLY APPlipetl.n Aae"Ied BY (// Det. A V Mee ' F Oreul hnpeetl4z a m by 'Data P"'""ten by Date � 0-11,etl.n I-P-tk-BY Date CerntetetNe• � r' - II 'f ACCOUNTING ONLY; AID# ;I. FAC# •!i L; ! PE CODES FEE INFO AMOUNT ATIOTTED CHECK.WMAGN RECEIVPSY DATE PEAMITISERViCE EQUEST NUMBER INVOICE _ r0 .00 MOO 13 13 gZI 19 (7 11 �I n Eh Pub Health Serv.-Enviro.173(1/97) a_ I