Laserfiche WebLink
APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ,� S•.• <br /> P.O,COX 386,304 EAST WEBER AVENUE,STOCKTON,CA 95201.388_ <br /> (2091468-3420 <br /> I\' <br /> NON•REFUNDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete In Triplkot/) �'7 1ra�V i <br /> AMICATON IR HERE BY MADE TO Tiff RAN JOAOUIN COUNTY FOR A PERMIT TO CONNTnUCT AND/OR INSTALL THE WOW DESCRIBED.71118 APPLICATION 119 MADE IN FOMIILIANCE WIIII tRANk <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CNAPTTE�R 9.11 16.3 AND TIIE TANOAnD8 OF SAN JOAOUIN COUNTY PUBLIC HEALTH RERVICEe,FN%AMNMENTAL 111µ'h1 T MmoN; I'/ 1 <br /> JOB ADDRERR/On APN#_gQ /�I- Y� CITY 1`r.j•)11' • : <br /> OWFIfn'R NAME �) PARCEL @I�Q/APNI !.' <br /> . r� ADDIIEAS O L_ /l1 AK)NE I �7 L1✓/—80,7 <br /> CONTMCTOR � �L��1/L ADORERS x365 w• _ S 87(7 <br /> --- ���L22,62 MgNE <br /> RVR CONTMCTOn <br /> ADnRF.eR LOC/ PHONE <br /> TY OF WEL MP• ❑NEW WELL ❑REPLACEMENT WELL ❑MON"ORINO WELL <br /> ❑OTINn <br /> ❑INRTALLATIGN ❑WELL RYRTEM REPAIn ❑CIIOONCONNECT nEPAIn <br /> ❑VAPOn EXTMCTIGN WELL I J <br /> ❑N—El P-.M N.P. DEP,11 PUMP BE7__FT. <br /> nyPE OF PUMP1 FRUIT WATER LEVEL 0 <br /> `�j(/ / ❑ <br /> our-or RERVICE WFL4 /, EO"IYBICAL WELL e ❑ BOB.SOIRNO <br /> ysLDEBT111/CT10N: �'�'/ (•�ciYT/— W /✓VLn Gt sIF/-- /� C (4. YD1� x �D <br /> //IH TENbEO UOE TTPEF W <br /> OE CONS/11UC LION BPECIFICAIIONi <br /> ❑INDUBimAI ❑OPEN OOTTOM DIA.OF WFLL EXCAVATION 8N A <br /> ❑DOMERTg1PNVATF. ❑GRAVEL PACK/917F IRA.OF CONDUCTOR CARING O <br /> tYl`E Of CARING/RTFEI/TNc. DIA.OF WELL CASINO 2`E <br /> ❑A/SlIf.MUNICH`AL ❑OmVFN nFPNI OF Onoi t RFAL O <br /> OPEGITICRAND N Q S <br /> ❑OOIOAtMN/AA ❑OTHER 0110117 OFA(,iNAtMlEO RV <br /> �y OnolIT RMNb NAMEo✓yA L et F <br /> ❑MONITORING 0110117 BFAL IM1IMPEO:xy� ❑Ne CONCRETE PEDESTAL By <br /> Omit ER� R <br /> APPROX.k.OERH LOCKING CIMMIT ROX/STOVE PIPE <br /> AIO►OBEO CONSTRUCTIONIIYONUMG METHOD:MUD ROTARYR <br /> Mn TOTAM AVOEn CAp1.F. OTHER <br /> IIM"Y <br /> /REGULATION <br /> CERTIFY 11E TIMI I HAVE PREPARED TitTY.R AI'.,OW,G AND THAT 711E—1——LI.RF.DONE IN ACCOm1ANCE WITH SAN JOAOUIN COUNTY or "A CEO,STATE UWP,ANO nULEO AND <br /> REGIMigN HE OA"JOAOUIN COUNTY.NOME OWNER On LMENMED AGEM'S mONATUnF CF.RTNIEB TIRE FOLLOWING:'1 CEIT7IFV TNAT INTHE r4Rf011MANCE OF 711E WOTK FOR WIItCII <br /> TIIIR PE IM(SRU ,'RN <br /> m/ALL NOT EMPLOY PERRONO RUpJE TO WORKMAN'S COMPENSATION IAWO OF CA IT nMA,•CONTMCTOR'R HIRING On OUR COMRACTINO SIGNATURE CEITfRRB <br /> 111E F tOWNq; •1 F.IRIFY THAT Vt <br /> ICE TiIE WOIE(LOn V'quCII t1118 PfBMIT IR IOOUF.O,1 BIIALL EMPLOY t'EneONO SUBJECT TO WORI(MANY COMIYNSATIDN UWS OF <br /> CAI.00R THEA CANT MUSIN CE FOR ALL nEOURFO IS TbNO AT 1}OBJ BOO N1fNO AT LOP XWEn ARFA 1'IgV1DF.b.PLOT PLAN M—I.NeN.I N.•t.0�NAMFS OP RTrKEtO On GOADS NOUNDING 111E t1O1(RTY, <br /> OVTLNIEOFT11FNOPF`n`V,OMAND NORTH DIPECTkIN, i,LOCATION OF NoURF SEWAGE D1RPo8Al SYSTEM On PnnTOBEn <br /> bIMENSOMb OUTUNFI AND LOEXINTINO AND PnoPOMEO EXPANOON OF OEWAOE DISrOBAL NYOTEMO. <br /> RTRI/CTUREM,INCLUDING COVEREA8 PATtOB,OIRVEWAYM,AND WAIXR. O•LOCATON OF WELLS WITHIN RADIUS OF ONE HVNINIEO fKiV FT. <br /> ON THE P/IOPEFRY On ADJOINING PnopentY, <br /> Sot � tl�� <br /> KW- 1 <br /> I <br /> 0"ARTMENT Ulf ONLY <br /> AnPSe•Ilnn ArnMIM PY ON• /O ' f ,,,• <br /> q"R A ��--Jr=_ <br /> OrmA Lnnnclinn pr L _D•ta r,—1-11—By D•1• <br /> n•r•In.;llen Imn�+tlon <br /> BY <br /> b•I• <br /> Cn.nmMx•: '�T <br /> ACCOUNTING ONLY:-----f MDI <br /> FACT <br /> PE COOfO FEE INFO AMOUNT RETMTTED C/IECKI/CARH RECEIVED BY DATE I'MAIT/OETIVICE REQUEST NUMBER INVOICE <br /> 01-7 4 <br /> Pub.Health Saw.-Enviro.173(3196) <br />