FIELD DOCUMENTS_CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CEmpI/IS M TrIpRnEI) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOADUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.111 B.3 AND THE STANDARDS OF SAN"AMIN COUNTY PUBLIC HEALTH SERVICES.ENNRONMENTAL HEALTH DIVISION. JOB AfORESIOR APII/3 f J iW�S1 Rte!'I,o 1'1 l VC'!)V'C. CHYY S7ToQcK+o /ni 1 P/A�RCEL 812EIAFNI OWNER'SNAME SiePfA LymiEfLcn tP L ADDRESS 3 /5 W!If A22ZCI11),;,"I %Tye• PONE/ 'Z2•943-777' CONTRACTOR Adv An.c eD CDS., knvha,'TM eA It" , ADDRESS YQC5 u-r1-714 LUb%.'1 SWLIC/ CAZZ PHONE/LO(j..V67^)6,G% SVB CONTRACTOR ADOMOR UC/ PHONE I TT�.1BF FLw• EMIy- TYPE OF WELL/PUMP. ❑ NEW WELL ❑ RFIUCEMENT WPL 11 MONITORING WELL 7 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CHORSCONHFCT REPAIR T ❑ VAPOR EXTRACTION WELL/ J ❑Nn ❑R.pw, H.P.__ DEPTH PIMP BET_". FIRST WATER LEM O DYPE OF PIMP ❑ OVI-0FSERVICE WELL ❑ OEORIVGICAI WELL I ❑ 801E BORNG B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS e A ❑ INDUSTRIAL p❑pETOPEN BOTTOM y �I111�1 �KrDIA.OF WELL EXCAVATION IIFJ /O ip OIA.OFCONOUCTORCABINO NA 0 ElDOME8TICMUVATE IDLGRAVEL PACK1817E TYPEOFCASINOISTEEU//I�1NC_TQ_,V(_ DIA.OF WELL CASINO qIE 0 ❑ PIBLOBMUmcIPAL ❑DRIVEN DEPTH OF GROUT SEALPIRP:A CSI" ' I-n'� ' SPECIFICATION Q R � ` T ❑ IRR[GATIONIAO ❑OTHER GROUT SEAL INSTALLED BY IJ //K. GROW{MND NAME &Ar bj 0 E MONITORING 11 (� GROIT SFAL PUMPED:,KYr [IN. CONCRIETE PEDESTAL SY DRILLERAYM ❑w SAPPROX.AROX.DIDTH MA:A;mTVm so"42£'1 1 cERBO OVEPPE "T-o B PROPOSED CONSTRUCT10NIMSLUNG METHOD: MUD ROTAW AIR ROTARY AUGER CABLE OTHER 1 HEPEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE LAWS.AND RULEB ANO REGULATIONS OF THE BAN JOACU N COUNTY. HOME OWNER OR LICENSED AGENT-9 SIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNEATION LAWS OF CALFOPSA.- CONTRACTOR-8 HIRING OR SUS<ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO WMIUMAN•S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 21 HOURS IN ADVANCE FOR ALL MOLIMEN INSPECTIONS AT H2OS)SSM 2". COMPETE DRAWING AT LOWER AREA PROVIDED. 'rte (" BlpmdX�r....y I TII1. �. jC� 5-) RFF UTley lO(iN i% ROT"Al lC`_1.S..I.I B..I. 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE MOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PIIOPERTY'.GIVING DIMENSIONS AND HORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G. DIMENSIONED OUTUNFB ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MENUS OF ONE HUNDMD FIFTY FT. STRUCTURES,PCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(S. ON THE PROPERTY OR ADJOINING POMITTY. 1U9AK , pR-rF Q MAy 1 �'I��S 0 , p DEPARTMENT we ONLY noon..11Fn Avaaplad BY na Or.ul ImP.FIbn By Ort. Pump ImP<tlen BY D.I.- ow. Dinlncllen ImPklbn By D.mmnrM.:�M�✓ � s o� � ..�� ACCOUNTING ONLY: AID/ PE CODES FEEINPO AMOUNT REMITTED CIIECKIMASH RECEIVED BY DATE PEMETISOIVICE REQUEST NUMBER INVOICE �� co G Z 0l6 3 86