FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

- � I APPLICATION FOR WELLIPUMP PERMIT SAN JDAGUIN COUNTY PUBLIC HEALTH�SERVI ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,344 EAST WEBER AVENUE, STOCKTON, CA 95241388 � 12091488.3420 iE NON-REFUNDABLE PERMIT 'I EXPIRES ! YEAR FRflMI PATE ISSUED , ICamPlab In TripIkatel 1i hp APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WITH SAN JOAOUIN UU/NTTY�YyM'tV ,g LENT TITLE,CHAPTER 9-111 S,3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS Abb�9iTlR�1PNR � ` � �}// /J 7/ CITI r�� j PARCEL SIZFIAPN#5( �'?�,Z OWNER'S NAME e ADDRESS I - CONTRACTOR �G{�,. ( iQ --- ADDRESS 3 �F SNE I r��t, a`� K LIC.- PHONE.14`�dGr . SU8 CONTRACTOR ADDRESS PHONE E u r4 ik TYPE OF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 i` ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CRGSS-CONNECT REPAIR I � ❑ VAPOR EXTRACTION WELL I ,1 � ❑New❑Repair H.P. DEPTH PUMP SET FT. I F FIRST WATER LEVEL p fIYPE OF PUMPI �-y ❑ OUT-Of-SERVICE WELL ❑ GEOPHYSICAL WELL X �1 SOIL BORING < 8 ❑DESTRUCTION: , Ih ' rI-N'tTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1' I{6 A LJ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMEBTICIPRIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINOISTEEL/PVc1 IjIy� DIA.OF WELL CASING p l ❑ PUBLIC/MUNICB'AL ❑DRIVEN DEPTH OF GROUT SEAL } JE SPECIFICATION A f ❑ IAt116ATI0WAG ❑OTHER GROUT SEAL INSTALLED BY_ry�� GROUT BRAND NAME f L^IT,/MONITORING f GROUT SEAL PUMPED: ❑Ys Llyve l} j CONCRETE PEDESTAL BY DRILLER:❑Yee Wfe 5 I� ., t APPROX.6EPTH_ _ LOCKING CHESTER BO%!STOVE PIPE i ++ S PROPOSED CONSTRUCTIONIMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER �1` CYABLE OTHER�lz-7J 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN IJOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGt1LATION8 OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEItHFIES THE FOLLOWING:'1ICERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SNA6 EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF { CALIFORNIA.' TILE A CART MVeT CALL-.24 URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT_120Y149227, COMPI..ETE DRAWING AT LOWER AREA PROVIDED. 11 f `I Slpned X Title L�� I I pale /O PLOT PLAN(DrewtoSame)8eele 'to ` T. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, �p14. LOCATION OF HOUSE SEWAGE DISPOSAL BYS'TEM OR PROPOSED f 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. I} EXPANSION OF SEWAGE DISPOSAL BYSTEMG, 3. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED 'a8. LOCATKIN OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. I.� ON THE PROPERTY OR ADJOINING PROPERTY. L ...: .-. .,i... ... k :... .. ', Orr' " jI Q r JC> OUIN'CCi�NtY :. :f pH SGN�Jz� S . $A� :.. .. . .. .. . .. ... PUBLIC NEAP ` - NTA' H�ADTH I]IV'ISiI N , _... t DEPARTMENT USE ONLY //J`[�)') 7 v�� L - Arae Groin 4NPeatlon BY < Dale Purnp Inspection Ry . Data I 1 OeelnrclFen IrnPectlen By 1 J 11 Orte y ACCOUNTING ONLY, AID;R FACT { jw i PF CODES FEE INFO AMOUNT REMITTED CNECx#tCABH RECEIVED NY DATE 1 PEAMITlSEHVICE REQUEST NUMBER INVOICE �p 2�- O D3��7rfl )� k Pub.Health 5erv.-ERVirb.173(3196)