FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMf .. SAN JOAQUIN COUNTY PUBLIC HEALTH SEhmES BOX ENVIRONMENTAL HEALTH DIVISION 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388 (209( 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (com "�Tliprkw- APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IIAND OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH IN COON. JOB ADDRESS/OR Amo 309 �/, GreNT' S�r<t'�' 1, / CITY 5[y 04 �e L^ PARCEL S¢F/APNI 100 E IOC) OWNER'S NAME I„ITorIP4 SKobrak / 5-1 ADDRESS 706 Al- EI Dera LSO Jy R10NEI �Y S'AZ6.7 CONTRACTOR dYnNo ee EFIN)pe +h7 �" L� yy I� E1 I/ _ ADDRESS Ip4Oj W HQP'GEI L„ uc,r PHONE/ S6 'O}6y SUB CONTRACTORMJC yIQI' DPIl(�y%y Ce PQ ADDRESS P.0.6•A 1 N 1J L• qq11 ],� R.Nc/10 ePCLIP67 617 PH NE; 657•-4556 NEW WELL ❑ REPLACEMENT WELL Ip1 MONITORING WELL#MW' 11INSTAILATION ❑ WELL SYSTEM REPAIR p❑I OTHER TYPE OF WELVPUMP ❑ ❑ CROSSCONNECT REPAIR pl VAPOR E%TRACTbN WELL! I T ❑New❑Repeh N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL -0 '1S J OYPE OF PUMP/ 0 11 ❑DESTRUCTION: OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL S ❑ WIL BORING B INTENDED USE TYPE OF WET. CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM ° IF _ A DIA.OF WELL EXCAVATION_ �, , IO DIA.OF CONDUCTOR CASING ❑ DOMESTIC/PNVATE ❑GRAVEL PACK/BILE _ _P y(� D TYPE OF CASINOISTEEL/PVC i DIA.OF WELL CASINO • U ❑ PMLICNUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 37 • SPECIFICATION S IL ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMEPe PT jdwGNpL�d„T E ® MONITORING qq P, GROUT SEAL PIMPED: ❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. e4 Ne S APRiOX.DEPTH 6A , S / LOCKING CHESTER BOX/STOVE PPE 5 PROPOSED CONSTRUCTIONIdtlWNO METHOD: MUD ROTARY AIR ROTARY AUGER_CARIE OTHFq I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•{COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL N HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200111NIJ420. COMPLETE DRAWING AT LOWER AREA PROVIDED.t/ sloped %7Fitt. Sthie► 574ff &f0li,ifT, Dot. PLOT PUN ID—to Ikol.l Sola •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FROPMED 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,AND WAIX6. ON THE PROPERTY OR ADJOINING PROPERTY. __ I ` ^. DEPARTMENT USE ONLY �'11Ay/�,IYc'/IVIW/^l/ !�//li). _ 11I/\T" Appllcatlen Accepted BY Otto Grein Impxtlen BY D.t. Pump 1n.p.ctl.n By Dot. De.nwtlen Imp«Oen By ate � r ACCOUNTING ONLY: AID/ FACS PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �� ( 00