FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL,/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompNh lot TrlpRt:s1#) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THRs APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN1- ';'k;9 CA.S /'��t�f/�(,(,�-j7a./fJ AjrX,C CITY f DAA;I UCA PARCEL SIZE/APNO OWNER'S NAME /"•'�h LrJ7��f- /�C �S�L"C L/L Jt'Il icy G'r`` ADSS l/ihX' J�c�1�51, 7 Z ]H4L �PI CONTRACTOR ftI"ZL ADDRESS NE 3 )) 'LO I RUB CONTRACTOR ADDRESS UC1 PHONE I TYPE OF WELL/PUMP: 2; NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 R YPE OF PUMP) ❑New❑Repdt H.P. DEPTH PUMP SET FT" FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM z DIA.OF WELL EXCAVATION rJ DIA.OF CONDUCTOR CASING H O ❑ DOMESTIC/PRIVATE 13 GRAVEL PACKMIZE / TYPE OF CASINO/STEELIPVC �[.V- yL� DIA.OF WELL CASINO L/ O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL E, SPECIFICATION ��C �{ R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY i N I-i a GROUT BRAND NAME ( J%'rJ-Arl �� E 18 MONRORINO GROUT SEAL PUMPED: ❑Y. ❑Ne ! CONCRETE PEDESTAL BY DRILLER:❑Y.a ❑Ne S APPROX.DEPTH ZLOCKING CHESTER BOX/STOVE PIPE ^ s PROPOSED CONSTRLICTION/ORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER K CABLE OTHER 1 HMBY 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 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"CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST rALL 21 HOURSIN A AMC*FOR ALL REQUIRED INSPECTIONS AT 12051 4!!442!. COMPLETE DRAWING AT LOWER AREA PROVIDED. signed x 'L"� -7 Title �/�•'if SCS /1r •�•►/ Date y PLOT PLAN(Draw to So.lel sad. I 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OARING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMO 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. :_ ... .....: . .'.... ]3t2AIKAI�� • p1.1 ........... ... A pt �---' o �Ir��le5�i'1 INw d W CLL ' DEPARTMENT USE ONLY G Appllealen AeeeplL c r li ed By ON. Ll Mr SI A LAI Grout I-Peetlen By '/�✓ 1 Date v p Impaction By Dat. nnatrtretlen Irwpectlon By ` Data � e ACCOUNTING ONLY: AID# FAC1 PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED DATE PERMIT/SERVICE REQUEST NUMBER INVOICE at Z� 0 89, 00 Z-q S / q O Iq Pub Health Serv.-Enviro. 173(1/97)