Laserfiche WebLink
8 ,,lau,s <br />2- dta rvi <br />DEPTH OF GROUT SEAL- St-tr.74 (a /9 X) <br />GROUT SEAL INSTALLED BY irenli R.,/09 <br />GROUT SEAL PUMPED: 0,Yes 0 No <br />TYPE OF CASING/STEE <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />A <br />DIA. OF CONDUCTOR CASING / <br />DIA. OF WELL CASING Z ' — dth re) <br />SPECIFICATION Sckgdwee. 90 P <br />GROUT BRAND NAME figai- <br />CONCRETE PEDESTAL BY DRILLER: 0 Yoe 11No <br />LOCKING CHESTER BOX/STOVE PIPE4.44 kieij 1) ex <br />AIR ROTARY AUGER X., CABLE OTHER <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SER, _S <br />ENVIRONMENTAL HEALTH DIVISION <br />PO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />co-5-v5 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <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 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN* <br /> 417 5ow.117-esnO Akenut._ CITY ,5&fhni <br />PARCEL SIZE/APN* <br />OWNER'S NAME — "Sae-ne.5 racxihi CO. ADDRESS f7! SaAit..e..s, 1754 rad v61/6/ 1„),. PHONE* 2.7 •9,s7 • 72g.3 <br />PHONE ,51C)- 43 -.5/o <br />uct 5/ 22 6 g PHONES 2 6?- SiEk547 /2_ <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />o New 0 Repair <br />(TYPE OF PUMP) <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />g MONITORING WELL I ifitieti- I 2. 3 0 OTHER <br />El CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />CONTRACTOR Cleaft*Afikr‘ (;7114/0 5z9 TThjrd,Ct 77 /D y ADDRESS /9ate/adni <br />-236s- 1,44.7 .ivaili ADDRESS C-4 <br />SUB CONTRACTOR sperztr-riky ) <br />UCS <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I <br />0 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />a MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />3() LOC) — <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />14 SOIL BORING 5e--1,2 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK WILL BE DONE IN ACCORDANCE WITH SAN 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 IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S 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 IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (205) 45434423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Dote <br />PLOT PLAN (Draw to Scale) Scala <br />NAMES OF ETS 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, AND WALKS. <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />SE 171/.K .b-1-6"0 <br /> <br />stye FLA/0 <br />oe. (4) ELL <br /> <br />130RI(3G- 1.,0c4 <br />fIc•2, , 5,6-3) <br /> Se <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date 4. <br />Area <br />Grout inspection BY Date Pump inspection By Date <br />Destruction inapection By Data <br />Comments: <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO OUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBEFI INVOICE <br />3501 S'q Li I LI L) Ylk_f2r-y 7-. i b .9 -1' L 30 IL <br />- <br />Signed X Title