FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT 16 AN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4683420 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 WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNyTTYPUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION✓ JOB ADDRESSOR A/PENN_/0157. cdr�SoN wg�c CITY SI 66'T'yt j " PARCEL SIZE/APNN / OWNER'SNAME4L�yAAY,t1D(Ll+ ADDRESS �Or 71 W�L,tT�C,wV .(l-I11A'Y� PHONE# J/4 CONTRACTOR.6�L'�)k0b LT ADDRESS 1863 W- A [T LlJ LIC# PHONE#15( r0 p�Sl3 1 SUBCONTRACTORIv� ya. WkyY1 3 4L �� 121vQ 4�5) LIC#7�1Z�aQ l� ADDRESS s-tr� 4 r PHONE 7 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL yt MONITORING WELL al 31 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repair H.P. DEPTH PUMP SET-17. FIRST WATER LEVEL 0 (TYPE OF PUMP( ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N SOIL BORING IF S ❑DESTRUCTION: ( ) -� IF INTENDED USE TYPE OF WELL CONSTRUCnOn SPECIFICATIONS A ❑ INDUSTRIAL r❑OPEN BOTTOM DIA.OF WELL EXCAVATION -5711/ DIA.OF CONDUCTOR CASING N At D ❑ DOMESTIC/PRIVATE yJ GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC n u/A [nyLDIA.OF WELL CASING �L l/ D 3S ❑ PIBUCWUNICIPAL /❑DRIVEN DEPTH OF GROUT SEAL / (oO 9 SPECIFICATION // R T,❑y IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME POILTLAN D I.G N7 E WJ'MONITORING GROUT SEAL PUMPED: ®Ys ❑No CONCRETE PEDESTAL BY DRILLER:Ely. ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DIBLLING 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAM'i COMPENSATION LAWS OF CALIFORNIAHE A CC/7NT MUSTCA24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209) 1141111 4,Z,3�COMPLETE DRAWING AT LOWER AREA PROVIDED. � SIO�wtl X� i"IA,ti/I/1 TUIe�Ta"U�J1GTiT /WI/vTT[/�Imo— Data �^��at�' `T L( PLOT PLAN(Draw to Scale)Stela "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 6EDISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATIOONN OFF WELLLLSS W WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. J DEPARTMENT USE ONLY - Data V Areal Application Accepted By ,JI p Date Grout Inspection By `—(�`` \ ( (,L rl�L' Dele r�L ump Inspmtlon By Date Destru non Inspection By COmmante: ,v ACCOUNTING ONLY: AID# FAL# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE LT- IZ2 O� Z