FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELUPUMP PERMI—. SAI. OAQUIN COUNTY PUBLIC HEALTH SE. ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comptoto In Triprit:ote) , APPLICATION IS HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIHIB APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE@,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/2 ,500,. S. _CRY /1rQ CV PARCEL SIZEIAPNI OWNER'S NAME W +r n (tet ' y 1'/O/^S"�,1DORE@B Z..bR /ot PHONE I_1Sy S6 r/ll7 CONTRACTOR 9 L/' `/1 _AODi1E6@ D ItiA�/ �. (r[A�L' 7 Q�O AiOHE I�7 3 7 y ZF'F/ run CONTRACTOR A-I! <'iLI Y'I r3-105� �' J � SjZ'S D2I ADDRESS 1�rsy /may � A LJCI RHONE TYPE OF WMIPUMP: tff NEW WELL ❑REPLACEMENT WELL y MONITORING WELL/, ` ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# ❑Nt-13Rep.Ir H.P. DEPTH PUMP SET__FT, FIRST WATER IEVEI O (TYPE OF PUMP) ❑OUT-OFSERVICE WELL ❑GEOPHYSICAL WELL. ❑ 601E BORING R ❑DESTRUCTION: 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ A ElINDUSTRIAL p❑�y,OPEN BOTTOM DIA.OF WELL EXCAVATION /� DIA.OF CONDUCTOR CASING D N1 ❑DOMESTICIP ATE 19 GRAVEL PACKISIZE�3 SI n TYPE OF CASINGISTEEIJPVC R-V L DIA.OF WELL CASINO 2" O ! ❑P/BLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 9 , SPECIFICATION R ❑IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ta MONITORING , GROUT SEAL PUMPED:❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Y- [IN. S APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCTION/DISLEINO METHOD:MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS Of THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT#8 ISSUED.1 61IALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOWS(FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T A CANT MUST 2 HOLIES IN ADVANCE FOR ALL REGUMMED INSPECTIONS AT 1200E 4SSJr♦22.COMPLETE DRANANG AT LOWER AREA PROVIDED. Mgn.dX •_ 1tl /`� y TIG. !!n—yZY- C -plt.3i'S� PLOT PLAN ID—to SoWel Se.I. 'to — 1.1.NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPOSED 2.OUTLINE OF THE PROPERTY.GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. See A �'ch�d s1 OFYARTMEIT USE ONLY A,11. ton A.ept.d By G—I-Potdoe BY oae IZ r� P—P In.P-fl—ny Da. D.t-0 n kwP.ctbn BY Ott. C-11- ONLY: AID# FAC. PE CODES FEE INFO AMOUNT REMITTED CHECK#PCASH RECEIVED SY DATE PESAITISERVICE REQUEST NUMBER INVOICE 0 9/ Pub.Health Serv.-Enviro.173(1/97)