WP0037768 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ?1 P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 96201388 1205) 480.3420 ' 1 OWNEFUNDANIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Trl (C"IBt9 1. t.lestB) Ai4UCAT10N b HERE SV MADE TO THE BAN JOA COUNTY FON A PER/y7 TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. TINS APPIJChiIOH IB MAO£ IN C:IMPVANCE WITH BAN JOAQUIN COUfTY DEVELOPMENT %TITLE, /CHAPTER 0.1 115.3 K ST DARDS OF BAN JOAQUIN /' COUNTY ALTH SERVICE!, ENVIRONMENTAL HEALTH DrAWON,,� JOB ADDRESSOM/A#446OR.OWS Ol y / ) CrrY �c-a PARCEL BIAiM1/ �yD-f�AC ✓a nWNER'S NAME_1 ADOPEBB S 1 f 10HE /:l 7 / �.Z� /J CONTFUCTOR� �1 „ [ 1 / rY C ADDRESS LYCr/oh:a -rs22-1SZ.}' PIiDNE r SVS COMMCTOR ADDRESS LIC IF PHONE f "Of WnLIFUMPI f t'T HELY YtELL ❑ REATACEMMr WELL ❑ MONrTomNO WELL r ❑ OTHER` _❑``INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CAO86tONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑ Nin 11R„dr H V. DEPTH PUMP SET FT. TRW WAT•GR LEVEL O HYPE OF MMPI Cl OUTOF-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ BOIL 80RING 9 ❑ OESTRIICTION- IN [NOm WS ryria-p2m CONSTIrUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION r SHA. OF CONDUCTOR CAMOU O ❑ DOMEBTICMMVATE �UORAVFL PACKISIZE_ TYPE OF CASINOIOTEELMVC DA. Of WELL CASINO 77 O ❑ PUNNUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R SYMOATION/AO ❑ of NER aHOVT SEAL Y16TACLE�D�-SAY /� 7 GROUT NANO NAM! - ! ClMONRORI NG r GROUT UAL pUMPfOf DO Vr ❑ N. CONCRETE PEDESTAL EMb Y RR1ER ❑ Yr 9 APPROX. DEPTH c �(CJ LOCKING CHESTER BOXfSTOVE RPE 5 PROPOS® CORSTRUCTIONIDISLUNG METHOD: MUD RRDTAT'_ AIR FIOTARY AUGER__ CMIE OTHER I HM9Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WDRK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND FIVLE9 ANO REGULATIONS OF THE SAN JOAOUBN COUNTY. HOME OWNER OR LICENBEO AGENT'S SIGNATURE CERMIEV THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERINT 19 ISSUED. 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOPKMM'S COMPSRSATWN LAWS OF CAiIFORNA' CONTRACTOR'S HNRIM OR SIJB�CONTRACTNG SIGNATURE CERTIFIES THE FOLLOWING- ' I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 leaAC, 1 SHALL EMPLOY PERSONS BUI JECT TO WORKMAN'S COM/iMSAT)ON LAWS OF CAL/FORMA-' T11R A"MAAN7 MUST CALL H W IM ADVANCE FOR AU JEEDURED INSMCTIONS AT IXA1 6093427. COMPLETE DRAWING AT LOW” AREA PROVIDED, 9101-d X L/ �4�MlY� �� TIu [ I C'% D..��Cl ROT RAN (Ort- to 9W.! 1, NAMES OF STREETS OR ROADS NEAREST 70 OR BOUMM40 THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSM SYSTEM OR PROPOSED 2. OUTLSIE OF THE PROPERTY, GRIM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OIVIO M 9YSTEMB, 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRROFOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE 14UM IED FIFTY FY. STRUCTURES, INCLUDING COVERED AREAS SUCH AN PATIOS, DRIVEWAYS, AND WALKS, ON THF PROFFRTY OR AO ,ONIM -- DEPARTMENT USE ONLY ,jry APPM«Oen Aoe.Pt.d BY D.[. (J _ MY a o' -t I -p -I n BY-'Flr. ll- By _ DM. D.t-llen k,4PeetNn By If — II ACCDONTINa ONLY: I AID$ I FACE II ►' CODES I FEF INFO AMOUNT—TT- c— " --m RECEIVED BY OATS PRMST/SOWICS REQUEST NUMPR INVOICE J� (_A 1,4, -7,.a4 I IJ7, ,IP1l,a I l; i/)J 1 _.,.,