FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT _ x3 r SAN JOAQUIN COUNTY PUBLIC HEALTH SERV `$ ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES t'YEAR FROM DATE ISSUED :(Complete In Triplicate) # 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 yANN.D�THHEE STANDARDS OFSANJOAQUIN COUNTY PUBLIC,HEEA�LTH'SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 3z/4 1r/ / / Z _!+!V i57X&-"/ CITY .y �'t>?1/�J '� PARCEEL�•7ASIITEIAPN# Ap .} OWNER'S NAME /d��A� ,toTl[4c_,T An/ ADDRESS �19.7O� 170-0 7,�-'/�A/ 1BRI`^ PHONE rle Y/'z—.PC 7L,SCJ CONTRACTOR ry[/Y�/rxFA 1CpiEQDA.GT�a`F✓ kyr AADRES.4r �'VYAOC &'r LIC#�ZZt2rPiiONE#Pd&eZ-?—J'�TS TRACTOR 1�-' - —+ l ✓ ADDRESS 'I LIC# PHONE# } TYPE OF WELGPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER J ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMP] - {/�//� �J 1:3 our-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ IL BORING 8 DESTRUCTION:_ // �fkA- C� c �1.. /�S .�A/—E'A - Mt✓-� /y�/—S� I INTENDED USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS i! A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O i ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CAIPNP dn -b ❑ PUBLiCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A WaifU ❑ IRRIGATiONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:11Y. ❑Na S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONSTRUCTIONMRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ii yLy I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND i REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1,SHALL NOT EMPLOY PERSON UBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "i IFY THAT IN THE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF SyrLIiedRNIA.' THE TCA ' IN AD ALL REQUITlt$RED INSPECTIONS 343 _M ��AT LOWERAREAVi ED. �� If//� Lr C G— PLOT PLAN(Drew to Scale)Style / _-"to SD 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. n } STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY .. A ' 10, i, S' P l ..... ,,-4 .... . + _ .. . . . �pZ - T" ,: ..., .. ........ tcP ... .... � ...... .... e. ��. ..... ,.,. . .............. -��, ., A +w � DEPARTMENT USE.ONLY _D _ __IY'. - - -.-�.�1f. --.a•Y. '��'-'� .: -.�... .�:...- ._ ...-. ...+tea'#�"u_ Y' Appligtlen Accepted By' MI Date �"��0�'- -- Arae 3✓0 Grout Inspection By Date. Pump Inspection By Date T Destruoticn Inspection By Date AWLU .VI l a ACCOUNTING ONLY: AID# FAC# A I PE CODES FEE INFO AjkAOUNT REMITTED CHECK#lCASH RECEIVED BY DATE PE MITISERVICE REQUEST NUMBER INVOICE I r k 4