SR0020287 - 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 _- r• -v � [-- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :c (Complete In T►Iplkatal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WH11 SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. ,+� 1 C ' JOB ADDRESSOR APN! L I - (I [ ' V'�"'/� V; fe •),� CITY L .,<7C�14,, j L 1 PARC/EL 81ZEJAPN! OWNER'S NAME L 1 ll'E� ('< V:t/IF):•� `SADDRESS_f/ 1 r-i`ii( O t� 1 r 4;+' V N�-i� � �)<' �I PHONE! CONTRACTOR r -_n -�. i�ZlP/' LIC! PHONE Ir• l SUN CONTRACTORy/ Z' LAJ b r-.' / 11 rl r, ADDRESS I`-. ll; � ALIC! PHONE / � ( � '� . � .- �;- � TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Y3 MONITORING WELL I 1. ❑ OTHER From � -0( C Co./Dept. ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J (TYPE OF PUMPI ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL ! FIRST WATER LEVEL ❑ SOIL BORING O S ❑ DESTRUCTION: INTENDED USE ❑ INDUSTRIAL ❑ DOMESTICMAIVATE PUBLIC/MUNICIPAL �❑y IRRIGATION/AG K! MONITORING APPROX. DEPTH TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ pp❑ OPEN BOTTOM DIA. OF WELL EXCAVATION :S A A C''. DIA. OF CONDUCTOR CASINO .L`! GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC 'rc: DIA. OF WELL CASING ❑ DRIVEN DEPTH OF GROUT SEAL 1�'c2 SPECIFICATION ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME_ GROUT SEAL PUMPED: ❑ Yee [IN. `` CONCRETE PEDESTAL BY DRILLER: ❑ Yee Cl No � LOCKING CHESTER BOXISTO RPE ?7✓I->(--� A D R S S LL it❑ PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER 1 HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAOU N COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, 1 SHALL NOT EMPLOY PER80NS 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 T14I8 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OP CALIFORNIA.' THE APPLICANT MUST CALL 4 POURS IN ADVANCE FOR ALL REGURED INSPECTIONS AT 12051 4SSJ423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 8lpnad X /rr 2 �1 V / Title / i ��'J Q(�� (�'I�►�l x? (�y�/1 Dets ,ji <-T / �I PLOT PLAN /Draw to Seale) Soafe ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE P'ROP'ERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED C 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLWFS 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. Applleatl- Acewted BY Grein I-Pe04- BR_ air fl—w.tlon IMPaetlen.* Cemm W A ' l Post -it" Fax Note 767 -Au at # of pages To' / (�(� A- f From � -0( C Co./Dept. Co. Phone #I g Phone # Fax # Fax # DEPARTMENT USE ONLY I -P-0- By Dale /YXMw ro J L Data arr.,.TINn ONLY: AID! FAC!11 5K� , 9 -7 PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH R CEI p DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �zOZ, •� Pub yealth Serv. - Enviro. 173 (1/97)