FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT WSAN JOAQUIN COUNTY PUBLIC HEALTH SERYL ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 9SM1,388 12091468-3420 PION-REFDIOOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete IR Triplkatal APPLICATION IB NERE BY MADE TO THE SAN JOAOUIIf COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE 1N COMPLIANCE WITH SAN JOAQUIN COUNTY OEVELOPM f!f TR CHAPTER 8-1115.3 AND THE BTANDARDO Or SAN JOAQUIN COUNTY PUBLIC HEALTH SEMICES ENV( NMENTAL HEALTH DIVISION. JOB AbbRE88f08 APN+ j PARCEL 912ElAPlN/Na4V I"`�"�14 OWNER'S NAME C ! .,., _ ADDRES Ole C G pNONE� 7�j/�22 CONTRACTOR /1/547 ._ ADDREBB 1/N LICN0-A2P7-PHONE I- L�[�Qt�I OUR CONTRACTOR n ADDRESS LR:+ PHONE+ TYPE OF WEILryU; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONnoRINO wELL+ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL+ ,1 ❑ RYPf OF PUMP) New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O 11K; OUT-OF-SERVE WELL 11OEOPHYSICAL WEt.i I I�SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELLCOHSTRUCTIDII SPECIFICATIONS A ❑ INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION 2.0 DIA.OF CONDUCTOR CASINO p ❑ DOMESTK:IPRIVATE ❑GRAVEL PACKISRE TYPE OF CASINGlSTEEUPVC DIA.OF WELL CASINO D ❑ PUSUCIMUNtCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRBIIIATIONIAG ❑OTHER GROUT SEAL INSTALLED BY L L� � GROUT BRAND NAME E LJ MONITORING GROUT SEAL PUMPED: ❑Yea RrdHe CONCRETE PEDESTAL BY DRILLER:141-. ❑No $ APPROX.DEPTH LOCKING CHESTEn BOXISTOVE PIPE 5 PROPOSED CONSTRUCTIONrMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER. I HE9EBY CERTIFY THAT I HAVE PREPARED T1418 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAH JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPMSA1q0N LAWS OF CAneLIFORNIA�',(iHE APP ANT MUST CA HOURS IN ADVANCE FOR ALL REQUIRED M110141111 AT 12001 4003427. COMPLETE DRAWING AT LOWER AREA PROVIDE 9led X-'-`LCL Tltfa Date !` / PLOT PLAN(Draw to Seelel Seala 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PnOPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 8YNTEMB. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WrTMN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAtKe. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY 7 App*atlen Aeoeptad BData '`�/' Area . Grout IMpaCtlon By Date Pump Inapxtlen By Date bealnKtbn I rP—tlon By Dole f ACCOUNTING ONLY: AID/ FAC/ y PE CODES FEE INTO AMOUNT REMITTED CHECK+ICASIf RECEIVED BY DATE PERM1TIBEAVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3136)