FIELD DOCUMENTS_PART 1 FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERL .8 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 16 777 A7DN/L�4NU �D. ��le S//71-? L.GOT)C ITY iQ 7HAeO,,9 PARCEL SIZE/APNI /qo y/av!OS OWNER'S NAME_ ✓• �• J/�/ISL/I/ ADDRESS /&/ 7/ 17QL/L!y/Vo ;CD, PHONE X CONTRACTOR /�E�T��^�iQ/g ADDRESS Qe7 2- Y�� ,QV/N/�/YL✓`,LICd p_PHONE# ��/III'pG8/(� SVR CONTRACTOR Sgt LTi2v/�/ L`�XPL OX4 IL)IV iH/� ADDRESS p�365 �/ljw1q-1 Die- UCN 2-2- p PHONE!'!6 S-p 712 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYP£OF PUMP) �g ❑ OUT-OF-SERVICE WELL ❑/GEOPHYSICAL WELL# ❑ SOIL BORING g K7 DESTRUCTION: �— S LIC s/f/V,a f�L�p'YF/�/7' G-,AZO V7 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH bF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT 'EAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: E BOX/STOVE Yes PIPE ❑CONCRETE PEDESTAL BY DRILLER:❑Yea Ne S APPROX.DEPTH LOCKING 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 IIAVE 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 I LIED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOL NG: CERTFY 17 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMFr IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO IA.' THE PPUCANT MVB CA 4-NO IN NCE FOR ALL REQUIRED INSSPPEECTIONS AT(2010)468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.. Slpned X Title PLOT PLAN (Draw to Scale)Scale to 1. NAMES OF STREETS OR ROADS NEAS O OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING ENSIGNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. Lo1-/5-EE ,gvC /90-05 - �i DEPARTMENT USE ONLY Appllcetlon Accepted By )(�t/V �V Vy"t'/ Date grea Grout Inspection By Date Pump Inspectlon By Date Destnrctlon Inspactlon By Date Comments: ACCOUNTING ONLY: AID# FACIE PE CODES FEE INFO AMOUNT R TT ED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE