FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

- 'PPLICATION FOR WELOPUMP PERMIT SA. JAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-(1�1�15��.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APPNNNCNRVAt ('�. -,rA, - I�CJIXXFY��}I�Ajb! _T,,j Wr CITY ifi,, rM !✓� PARCEL SIZE/APNX OWNER'S NAME .��.)��i.,ru�IZ.{t-�jry t Fek—_ Awd ADDRESS 00 COq/N(O�2sC-_ S� 'LUNO, 64 q f0_66 PHONE N "� p /� CONTRACTOR -t�v-t �^V�/�� (\n j7wc ADDRESS &!;IC /t'/Ru, Sf}�C^. UCN r� -7�2 PHONE�N�6'-44y-�9_?7,7 SUB CONTRACTOR ✓y1'',-NC- D4_LL 4G ADDRESS?Q� �,�GOLNt 6"A UC# 7/CV�� PHONE#M-01 t5 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL X ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* LJ SOIL BORING 4,��WCr 7Zd N p'7 BLrQj rB ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /{ y DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 'y\6'7 / . SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 1)41LLlatS. GROUT BRAND NAME_JY�E r'� "U) E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:[1Y. ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRI LUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AP CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X -_-'` -� Title eC20- Date 7 Z Z /,) PLOT PLAN (Draw to Sine)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1' . .. . 617 _ 3 . .... 961"L �` _.. . ......... i©G�r+��hJ .._ ... .. .. ... .. .. ,. ..... .._ rr ,, rr�� .. .. .. ....... . . ..... :........... ...... . ...... .. .. .. .. ............................... 617 .. ............... .. (� ( 6r7- 2 .. ..... .. . .. ..... ..... G� _ ........................ .. ........ . ......................... _ ........ .. ............... ...... ............... ......... . .... _ :........ ................,.................... ,.... .. :..... ....... ...........................................:.............. . :............... .. .. : .. .. .. .. . .. �j ('chwcr 6'/ 7 IN o c�+ ........... ............... ....... DEPARTMENT USE ONLY ---9�s6 Application Accept y �"� Date LSA-/ Arm LIL Grout Inspectio Date Pump Inspection By Date Destruction Inspec on y Date Comments: ACCOUNTING ONLY: AID* FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE v{,iV