FIELD DOCUMENTS_1997 - Laserfiche WebLink

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PLICATION FOR WELUPUMP PERM'" SAWMAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HIM BY MADE TO THE BAN JOAGUN COUNTY FOR A PERMIT TO CONSTRUCT ANDRM INSTALL THE WINK OESCPIRED.THIS APPLICATION IS MADE IN COMPLIANCE MUI SAN JOAQUIN COUNTY DEVELOPMENT TOLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVE;IDs Lo'. Plan. JOB ADDRESSOR API# 3774 LincoollnnDCenter CITY Stockton PARCEL SIZEIM 0I/,�aZfa9 $ ONMSETLING_ER BYNAME C/oYDonald TG BradshTSLev(ines ricke-ReconAmREee 1900 Powell St 12th Flr. Emerwill®HONEe 1510)652-4500 COMPACTOR ADDRESS UC# PHONE# 1135p Monier Park Place (9166 PUB CONTRACTOR Transelobat environmental Geochemistry AODnESB Rancho Cordova, CA 957421ce 706568 PHONE 9853-9010 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM SEPALS ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J ❑New❑ReOelr N.P. DEPTH PIMP BET_FT. FIRST WATER LEVEL a RYPE OF MMPIEl GEOPHYSICALWELLS OW-OFWELL ❑ GEOPHYSICAL # SOLI.ROMNO V APoR - ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I-TNCH DIA.OF CONDUCTOR CASING NSA D ❑ MMESTICIPIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINGISTEEUPVC N/A DIA.OF WELL CASINO N/A D ❑ RIPLICRAUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL N/A SPECIFICATION cement-bentonite A ❑ IRRIGATION/AG ❑OTHER GROW SEAL INSTALLED By N/A GROW BRAND NAME N/A E ❑ MONITOMNO GROUT SEAL PUMPED:Uy- [IN. CONCRETE PEDESTAL BY DPLLER:❑Yw ❑NP N/A s APPROX.DMH multil2le borinec 5 to 45 It bgs LOCKING CHESTER BOXIWOVE RPF s PROPOSED CONSYWcYU,NSVVLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CARIE OTHERHVl1TflLL11C Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCOILGANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED ASEM'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH TIIIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF CAUFOMIA.• THE AP,PJ�CART MUST CALL 24 HOURS IN ADVANCE FOR ALL ASSURED INaMTONe AT 12001409 A23. COMPLETE DMWING AT LOWER AREA PROVIDED Brox `]tel �� TRIS Site Project Manager D.I. O[ � PLOT PLAN IDI-Ie excel Beela 'le / 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE P OPERTY, 4. LOCATION OF HOUSE EWA SEWAGE ALSYSTE SYSTEM OR PfROlO8E0 Z. OUTLINE OF THE P10PRTY.01ING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN IVIG PR PE ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, l w ' LVMD - '1 '\ \ A CPT-202 i M W 4 t iL _ CPT-207 I mo-'• Mw=30 .. ., CPT-215 v CPT- P7 217 Ci CPT-?Ds- - ~ yLVM ..'- LCPT-210....- CPT-,214 •' , , 1 _. . .CPT-218 ,g 14 CPT 21@ t .L CPT-204 k i DEPARTMENT USE ONLY 5 G/ A,01.0..Aeaepled RY 1�'- '" � _ -_DeN �•`� I � NY GIO,A IMPMIon BY Deb PE0I IINPSRIen BY Dae OMbeellen IMPKIbn BY Deb __ Demn,e,N.:��G L�1'L'L' DA�Ylvxar>d" GEr✓A Ld" 4 �. 304 L 5� a" G Z•9 I�oI res 11•I \II ACCGUNTINO ONLY: AID# FAC# PE COOPS FEE INTO AMOUNT REMITTED CHECK#ICASH RECOVER BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 2� g D 55 Pub.Health Serv.-Enviro.173(1/97)