ARCHIVED REPORTS_XR0012163 - Laserfiche WebLink

Home Browse Search

UAPPLICATION FOR WELLIPUMP PERMIT U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N SAN JOAQUIN ST,STOCKTON,CA 95201 388 (209)458 3420 NON REFUNDABLE PEAMIT EXPIRES i YEAR FROM DATE ISSUED [Complete IR Trp1mataf APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR WSTALL THE WORK PESCNUED THIS APPLICATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8 111115 J AND THE STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOB ADORE,gpR APHN y37 67451 //'r/Mel /�verl Ker CITY 57 oe_k'r' n 13i� oz,4-a7 U PARCEL alzerARl-F OWNER a NAME H O G!a I O/' O/'u I7 d Y/ IJ �,� $/jS „j L Fy A� r f /, //�� ADORES6�_�7 y�QF Al4ArlcrrT / �1 5-14-Z77-273'311 / y CONTRACTOR_ rj1 !{f 4E•,L{/ G 71 V Al� AOORE6a X Z I I� SUBCONTRACTOR E� ADDRESS �/ [] I �F10E PHONE/ TYPE OF WELLIFVMP t HEW NRLL ❑REPLACEMENT WELL 1�MON[TOPINO WELL /F l- —V1-a ❑OTHER y P,IN57AlLATON 11 WELL SYSTEM REPMR •O'CAOSS-COkNECT REPAIR ❑VAPOR EXTRACTION WELL/ J ITYPE OF PUMP[ ❑N_❑Rep•k H P DEPTH PUMP SET- " FIRST WATEA LEVEL O ❑OUT OF SLAVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL SURING S ❑DESTR11C7ON ' INTENDED V49 TYPE OF WELL / ,{�� CONSTNVCTION SPECIFLCATIprya It A ❑INDUSTRIAL ,a❑,gyp PEN BOTTOM Y&A,5A_` DIA OF WELL EXCAVATION ff/J qZ DIA.OF CONDUCTORCASING D 111.1 DomfoTICRWVATE IQCIvyEL pAGUSRE J HYPE OF CA61NGlSTEEL,IPVC_ ��-EL) r y Ci DIA OF WELL CASING O 113 PUSLICIEAUNICIPAL ��❑GFUVEN DEPTH OF GROUT SEAL I"�� • SPECIFICAT ON Q (EQ-JY'EG�T R IJ IRROATRINIAG ❑OTHER i GROUT SEAL INSTALLED BY--"rI L� E I POUT BIWJD NAME } ONTTORINO �l�" GROUT SEAL PUMPED ❑yw • CONCRETE PEDESTAL BY DIULLFH❑ROY- 5 APPX DEPTH LOCKING CHESTER SOXISToVE PIPE S PROPOSED CONSTRUCTIONRIWLLlNO METHOD MUD AOTAAV MA ROTARY AUGER` CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAUUIN COUNTY OADWANCE6 STATE LAWS AND RULES ANO ' REGULATION 8 OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT S SIDNATIIRE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CAUFORSAA CONTFACTOA S MIRING OR SUBCONTRACTING SIGNATURE CERftFIEB 1 THE FOLLOWING CE"'I T"AT IN THE PERFO AMC E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S CpMSIGN AT RE LAWS OF 1 I CALIFORNIA TH APpUCANT VST CA 74 ! �ADVANC-1 FOR ALL REQUIRED INFPECTIONe AT I2oeI AHJ1 7 COMPLETE OMWIHG AT LOWER MEAN S COEP j �" /v ILC' I TItI.��PO JF c r s1e.e x G ..E _. PLOT PLAN IDr-1•Sul.)Be I. 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7 OUTUNE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPDSAL SYSTEMS 7 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED 6 LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT I�1 STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR AOJOINlNG PROPERTY I Ln + Ex's-fRlig wfI S i U-5 I Lao"C (+ e u � � r v 1 DEPARTMENT USE ONLY APPEutbn Aee.pR.a BY ! I Cc.• I C a/'---yam Greta In•p•erlen B1 D•I• IN—P INpx,l•n By D.R. R Drvunbn I�.P.rrrl•n BY D•,• ACCOUNTING ONLY AIDS FACT PE CODES FEE INFO AMOUNT REMITTED CHECKSMASH ILECE7yEo BY DATE PERMITISmmir REOUrAT NVMBETt 1 NVOICE �Z n uCa�