Laserfiche WebLink
4PPLICATION FOR WELWPUMP PERMIT - <br /> SAI,,.,i,JAQUIN COUNTY PUBLIC HEALTH SE, CES <br /> ENVIRONMENTAL HEALTH DIVISION 1-1 <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NDN•REFUNDADLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IAND/on INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> TITLE,CHAFFER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADDRESS/OR APNI_ 1 Cil l' 2� <iy� 1 e./ CITY '�"�, 15-1_ 7 -3 y <br /> {� / PARCEL SIZE/APN# /.�— <br /> OWNER'S NAME �1Y�i11S ✓+��. < �-4- r s <br /> Q ADDRESS PHONE e J jJt� <br /> CONTRACTOR1)' i It '1/ A•✓4:�l - J L S ADDRESS :5LfS j'� �'E-• p R- <br /> / UC# PHONE phi�J 1r3•/�� <br /> OUR CONTRACTOR__ s r Q�/' ; / .��3� <br /> vv �^ LAC =�-�PHONE 9514-V <br /> TYPE OF WELL/PUMP: ANEW WELL ❑ REPLACEMENT WELL Pt <br /> MONITORING WELL# F'`�' ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> J <br /> New 13RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) O <br /> ❑ <br /> DESTRUCTION: OVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING <br /> B <br /> INTENDED UbE TYPE OF WELLC <br /> CONSTRUCTION SPECIFICATIONS IR <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION _ <br /> 11n OLA.OF CONDUCTOR CASINO A <br /> �/ <br /> ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC � <br /> _ r r /�V DIA.OF WELL CASINO_ 7 <br /> ❑ PUBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL SPECIFICATION D <br /> ❑ IRRIGATION/AG AOTHER R <br /> GROUT SEAL INSTALLED BY ,,..�s� GROUT BRAND NAME E <br /> .�rb'� <br /> V MONITORING GROUT SEAL PUMPED: ❑Yea <br /> ii��..i- L4 ❑No CONCRETE PEDESTAL BV DRILLER:❑Yss ❑No S <br /> APPROX.DEPTH 7© N I"'' LOCKING CHESTER BOX/STOVE PIPE <br /> S <br /> PROPOSED CON8TRUCTION/DAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITHBAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I8 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.' TI(1 APPLICANT U6T CALL 24 HOURS I A ANCE FOR LL REQUIRED INSPECTIONS (208) 66-3421• COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> signed x �iC/4 'w -0✓• i� r ,yl.. <br /> Tltls (��, �i�tb c.' 1 "� Data .��, 9 <br /> PLOT PLAN(Draw to Seale)Beale •to_� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR 8LNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On Pnor'OSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> X. <br /> 40 <br /> Lxp�nya�oa, �' <br /> . .,....:... : <br /> Ana Pi'S�"�( �l'./ot•. fCt r'i n j- ! _ <br /> Nit 3 <br /> - __ M1, � <br /> � . <br /> 1v <br /> 4 <br /> DEPARTMENT USE ONLY <br /> Applleatlen Accepted Bye, DoteD J � I / Area <br /> Grout Inspection By Date Pump Inspeetlen By Dale <br /> Destn,ctlen Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 'D S� 13 Lai <br /> Pub.Heafth Serv.-Enviro.173(1/97) <br />