Laserfiche WebLink
" to <br />Location of house sewage disposal system or <br />proposed expansion of sewage disposal systems. <br />Location of wells within radius of 150 ft. on <br />the property or adjoining property. <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />1 <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />ICempleteie TriplksteI <br />Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />City ...4:77/A.) Job Address/or APN# Vi /1/' rrA-J.it4"-4,) Parcel Size/APN# ( <br />Address /'C' gc'X 2r3Vi (slx-4) Phone # <br /> <br />Address 65 ev. (4) -0;4 Lic# Phone # N.; ()24,V <br />Address 3>4" AC. &NKr/A-Lice 1.5W67,6 Phone #.07- 7 ,P•292-2/ <br />Owner's Name ')//"5.i..7-C7/1?-7,-",4-4t-t-7- <br />Contractorkgritc,,,?aild,-", <br />Sub Contractor ' <br />,k14EW WELL <br />Ti DESTRUCTION <br />INSTALLATION <br />(1 New Ti Repair <br />II REPLACEMENT WELL <br />0 OUT -OF-SERVICE WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />),1 MONITORING WELL # (1) */712711"1 OTHER <br />0 GEOPHYSICAL WELL # <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />SOIL BORING <br /> <br />0 VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL <br />CONSTRUCTION SPECIFICATIONS <br />El INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION gli DIA. OF CONDUCTOR CASING <br />II DOMESTIC/PRIVATE II GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Pt/4, DIA. OF WELL CASING <br />0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL 85 ' SPECIFICATION .Set VD <br />II IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED B1 774' GROUT BRAND NAME ii.Wrldiri0-1.) <br />II MONITORING GROUT SEAL PUMPED: 0 Yes'-,0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE /-X4,77Y1-c g‘.0.,._ ty,,s ,,,.... <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER yCABLE OTHER <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br />certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br />Laws of California.. Contractor's hiring or sub-contracting signature certifies the following: . I certify that in the performance <br />of the work for whic this permit is issued, I shall,employ persons subject to WORKMAN'S COMPENSATION Laws of California.. THE APPLICANT <br />MUST CALL 24t19 S N DNA E FOR AL EOUIRED INSP TIONS AT I2OSI 402-3423. Complete drawing at lower area provided. <br />Signed X Title X vdez t Date <br />INTENDED USE TYPE OF WELL <br />PIAT PLAN (Draw to Scale) Scale <br />Names of streets or roads nearest to or bounding the property. <br />Outline of the property, giving dimensions and North direction. <br />Dimensioned outlines and location of all existing and proposed <br />structures, including covered areas such as patios, driveways, <br />and walks. <br />‹E r -fitrIT A 7- <br />DEPARTMENT USE ONLY <br /> Date 6ump Inspection By Date <br />Date Area <br />Date Comments: <br />ACCOUNTING ONLY: AID# FAO, <br />PE CODES FEE INFO AMOUNT REMITTED (fiElINICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />5s9 ) JA/Th 25 - v/i ov_c) zi.411217.-.:;