FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICITiON FOR WELLIPUMP PERMIT -SAN JOAOUII. COUNTY PUBLIC HEALTH SERVICn ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209( 4683420ORIGIy �� NONNREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TTip6Eatt) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.33 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HE,A,,LTTSH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSMA AP/NY/ _C/-L L�I 6, ��ttnc I l �r CITY 5/ llck/�prV�'/Ly� /'.�//.PPARCEL SIZE/AMOL53-a)8o-o8 OWNER'S NAME �c/"J l'wL/ O(`/,A ADORESBfI Dr�O X�1Od/n 4rT(�L �// PHONE AI'1Q�i�S.S]��-Z7M CONTRACTOR CT-T I°.Qq 1 II I I`Q —ADDRESS-9-5-0 "DI^''t- RGI LICi 5,65 moNEi6I6-3L/J/JW SUB CONTRACTOR Iq ADDRESS �[ LICi PHONE i TYPE OF WELL/PUMP: V,NEW WELL ❑ REPLACEMENT WELL LK MONITORING WELL i 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i ✓ ❑Naw❑Repair N.P. DEPTH PUMP SFT—FT. FIRST WATER LEVEL O ITYPE OF PUMPI ❑ OUT-OF-MFWICE WELL ❑ GEOPHYSICAL WELL i ❑ SOIL BORING B ❑DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q ❑ INDUSTRIAL ❑1qq OPEN BOTTOM / DIA.OF WELL EXCAVATION O (t/ DIA.OF CONDUCTOR CASING D ❑ DOMESTICS IVATE MGRAVEL PACK/SIZE#;Sand TYPE OF CASING/STEEL/PVC PVC- DIA.OF WELL CASING" 21( D ❑ FUBLIC MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 9()—36-I SPECIFICATION SCA ({O R 11IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY DY Y L1L ^ GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Year [I No 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPL g PROPOSED CONSTIEUCTIONB RILUN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'l CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY 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 WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' THE APPIJ MT UST CA 24 HOMe IN ADVANCE FOR ALL REQUIRED IIMNNS��P,,ECTION&AT I=UtI 4"A4t0. COMPLETE DRAWING AT LOWER AMA PRI 61Smd% / Till./////�J/�t(Q�f / �2 2aj ` Data T /# PLOT PUN (Draw to SealeL Scala 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY'OR ADJOINING PROPERTY. DEPARTMENT USE ONLY 7/ /Tvry Application Accepted BY Data a `� • "' Area Gram Inspection BY Dau Pvmp Inspection BY Date Desouption Impaction BY Data Commenu: ACCOUNTING ONLY: glDi FACS PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PEAMITISERVICE REQUEST NUMBER INVOICE 1 Mui