FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION OR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH Sr-11ICES ENVIRONMENTAL HEALTH DIVISION P.O. �R 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 , (209) 468.3420 MOM-REFUNDABLE PERMIT EXPIRES 1 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 F* IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ZOEJOB ADDRESSOR APNO W.W rsP 6&-4ov L Nc E ei -ALf N ZA.OS CRY rz-4ew PARCEL SIZE/APNE 011144.6% OWNER'S NAME t�A2QD2A f7"&L Cf7&ti _IM'. ADDRESS_Z430e/asA,q(r `,4&'Or S712 GlAL�, C PHONE E(S/ 4-74-6677 CONTRACTOR (,a.�RTE.c, Il�.fc{�p�„Ayf c�t_ts�iwr•, .�f (t,;J>CADDRESS"in Al- 6+} r-G?� UCKa2LA PHONE�f6)lrz�a9as SUB CONTRACTOR ADDRESS LK:E PHONE t TYPE OF WELLIPUMP: ❑ NEW WELL KN REPLACEMENT WELL X MONITORING WELL E M W•2A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLE (TYPE OF PUMP) 13 N..13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION In-C-t r DIA.OF CONDUCTOR CASINO ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/81ZE TYPE OF CASING/STEEUPVCAa QVG _&[liiOuLa-*D DIA.OF WELL CASING ALN ❑ PUBUC/MUNICIPAL ❑ VEN DEPTH OF GROUT SEAL .Z " -41 6r a. SPECIFICATION ❑y IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY 110w_ GROUT BRAND NAME 00 MONITORING `- �nf�' GROUT SEAL PUMPED: ❑Yea ,RN. CONCRETE PEDESTAL BY DFuL1ER:13 Yea Ow & � APPROX.DEPT.�Sd44 �S LOCKING CHESTER BOX/BTOVE/PIPE S PROPOSED CONSTRUCTIONAMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER f�tlOuiR1M CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR-8 HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA.' THE ANT M G IN ADVANCE FOR Atl REQUIRED IN NS ATM--3422---3422- COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Tltla r 4-;=G C/./��_OLO t:ati Data PLOT PLAN(Draw to Sole)Soala 'to 1. NAMES8T 8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE F THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. IT 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WHIN RADIUS OF ONE HUNDRED FIFTY FT. 11Y STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. - ON THE PROPERTY OR ADJOINING PROPERTY. .. :.. S.zr AP o� Application DEPARTMENT USE ONLY Application Accepted By Date f Mw Grout Inspection By Date Pump Inspection By Date — Destruction Inspection By . Date Comments: ACCOUNTING ONLY: AID+1 FACT PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIV BY DATE PERMIT/SEAVICE REQUEST NUMSER INVOICE 2 o r NSW � Zo z s 6 ov