FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SER%%,a ENVIRONMENTAL HEALTH /DIVISION P,O, BOX 3M 304 EAST WEBER AVENUE, STOCKTON, CA QMI-See i (209) 408.3420 , MOM•REFUMOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complot6 In TEWints) APPLICATION IB 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/ i JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS'OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. : JOB ADDRESMOR APR# � 1 CITY PARCEL SIZFJAPN# OWNER'S NAME I �� ADORES PHO E# 23— •. . CONTRACTOR �(/ j^ r ' ADDRESS�O S � ' �# /PHONE# SUB CONTRACTOR h 14 ADbRESB /y��`� v�� ✓ r ' LIC PHONE 6 TYPE OF WELLMUIiMP: ❑ NEW WELL ❑ REPLACEMENT WELL ! J MONRORINO WELL#�/`1y ❑ OTHER - F` ❑ INSTALLATION ❑ WELL SYSTEM REPAIR I/❑"CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair M.P. DEPTH PUMP SET ITYPE OF PUMP; FT. FIRST WATER LEVEL U ,, ` ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ 801L BORING .DESTRUCTION• ! ,- t/ r , INTENDED BE TYPE OF WELL CONSTRVGTION 6PECIgCATIONi �F A I ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO , ❑ DOMEST /PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC 6 DIA.OF WELL CASINO p ❑ R/BLlCIMVNICIPAL ❑DRIVEN °t DEPTH OF GROUT SEALS SPECIFICATION R i ❑ IRRIGATKINIAG ❑OTHER r-' GROUT SEAL INSTALLED BY GROUT BRAND NAME E I ❑ MONITORING '� GROUT SEAL PUMPED' D Yds ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne ,i S APPROX.DEPTH ` LOCKING CHESTER BOXISTOVE PIPE S e PROPOSED CONSTRVCTIONMRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMNY CERTIFY THAT 1 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 WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SU"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH,THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA=APPUC MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTNINB,AT{ 1466.342!, COMPLETE DRAWING AT LOWER AREA PROVIDED• i3 i ) Signed X C TIt]e /.S Dots / -.. PLOT PLAN/Draw to Scala)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. F 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED t 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS 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. qHw- .. . .. .. - . .. . . - ' saa�- -ar+� r•sts'rix•• i:�.ar.:�.a,�e: -..-. �:�:�:�';�t;r •� �Ps.,r�.l -,,. 4� - •:.»..�- .w-cMr.�,e•-r.w-.Sr:' DEPARTMENT USE ONLY `_ r' 6 Application Accepted By::)Jd Date / 31. , Ataa Grout Inspection By Date Pump Inspection BY Date ' Destruction Iruppptteecch/�/Ion B�Y�{ �y / / Date Comments: Y L1(.a< L.H. {I.f< �D4 CP u -7 _ 7 ACCOUNTING ONLY: AID# FAC# 1� - PE CODEB FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY 'j DATE PERMIT/SERVICE REQUEST NUMaat INVOICE oln$50