Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. ElOX SM 304 EAST VYEE M AVENUE STOCKTOR CA 81 01 X IG <br /> {209) 408-3420 <br /> NOWMU■DABLE PERMIT EXPIRE 1 YEAR FRONT OAYE 11<iU� T ' 1 �b20^ 11'�!9I-`,3 ; <br /> IC+BI�IBte In Tri'Yw19) L &c)I <br /> APPLICAfgA 19 HERE:BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONVI'MIICT AMMR INSTALL THE WOW DESCNBED.THIS APRJGITION IS MADE IN COIOPUANcE WITH SAN <br /> JOAQLIN COIN.ITY DEVELOPMENT TITLE.CHAPTER B-1 it 5.3 AND THE BTAHOARDS OF SAH JOAO1lIM COuap!x <br /> HEALTH SERVICE8.INNAVON�ITAL HEALTH DNIMM, <br /> JOB.AGORESA OR APN! -CITY am PARCEL*MAW,,# <br /> oWTMNERrNr NAME 1143�fN1G # ,AMID P LIM FV0NE! W- <br /> CONnucroft ADDRE88 6925 F,Mui" LICA PHONE! ^13 <br /> OUB CONTTIACTOR I� ADDlBiS6 �i!T .]�tV� IMC! R/0NE! <br /> e TY�OF tMo ❑ raw WELL ❑ REPLACEMENT WELL ❑ mowrORIIO WELL Nr ❑ OTHER - <br /> TYPE WOLL <br /> ❑ wwALCATNON ❑WELL wnmEM REPAIR ❑ C"08&cawmcT REPAIR ❑VAPOR Ex'r"AACTON WELL! J' <br /> ❑NNw❑Repdr H.P. DEPTH PUMP SET FT. FIRST WATIM LEVEL D <br /> IT1fPE OF PUIMFJ M <br /> © 011r-0F6ERIACE WELL ❑ GEOPHYSICAL WELL! SO.B.,.AaORSm 71 t< � �fGm <br /> )OESTIIUCIMM: { ` _�IJL�I W � L!3 <br /> N <br /> HWATHONIB , <br /> ❑ NDUST/BAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION SAA.OF CONDUCTOR CABNG <br /> ❑ DOMESITC/PNVATE ❑GRAVEL PAu(mzE_ TYPE OF CASBIGISTEELIPVC DIA.OF W[iL CAW0 <br /> ❑FUSHJCARIISCIPAL ❑DNVEN DEPTH OF GROUT SEAL — SPECIFICATION <br /> ❑ RRRIGA710MIAo ❑OTHER GROUT DEAL Mf STALED GY GROUT BPJ MD NAME <br /> ❑ mowrONENA GROUT SEAL PUMPED. ❑Yr ❑N. CONCRETE PEDESTAL WY DIIBN. t:❑Yrs ❑m <br /> } APNIOx.IEF'rM LOCKING CHESTER BOXWOVE PIPE_ a <br /> "MMS®CON STRUCTIONIONLUNG MRFgO: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TYJAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNNY ORDI NAAM8,STATE LAWS,MIO RUZWM <br /> + REGULATIONS OF THE SAN JOAQUIN COUMrY. HOME OWNER OR LICENSED AGENT'SIG <br /> SNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE NCE OF THE WORK FD <br /> TWO PERMIT IS ISSUED.1!HALL NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS OF CNJMF"A.' CONTRACTOR'!MINING OR SUB-CONTRACTING WGNATURE C <br /> THE FOLLOWINS: -1 CE'RTWY THAT N THE PERFORMANCE OF THE WORK FCR WNICHI THIS PFll1MRT IS ISSUED,I SHALL EMPLOY PERSONS NRIS,IECT TO WRRORISIAM'S aWIPSAATON LAWS OF <br /> CALIFORNIA.' APPLICANT HNOURS IN ADVANCE FOR ALL RSOMED MM.S�FB`CTj* AT 12WAI4418-422. COMPLETE DRAWING AT LOWS!AREA PROVIDED, <br /> v4plad x ft GJ <br /> ROT RAIZ B>,rw 14 SeNhl SOW 'GN <br /> 1. RE <br /> NAMES OF STETS OR ROADS NEATEST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF/OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> t. OUTLINE OF THE PROPETRTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOM SYSTEMS, <br /> S, WMENSIONED OUTLIES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE H INID ED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED MEA!SUCH AS PATIOS,DNVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOIINS PROPERTY. <br /> .... .„ .. ' <br /> i <br /> - <br /> - - go <br /> gos_ <br /> ' - - <br /> 2. <br /> Cukl <br /> .1 r HAIR <br /> .. ......... <br /> JAC, <br /> 1Citi7 S1O�i.. <br /> Cft� lr� iF1� �}t <br /> .. :. .. .: ;. .< . <br /> DEPARTMENT lb[ONLY A"ftWm AaeNpwd eY� Dam _A <br /> M-2 J10 <br /> Grein InIpm Ion By N>iNN Pump trwwtlen By _Dots <br /> O�.Inrall�irr#eollon By Dot ' <br /> fpfcACCOYMTING ONLY: AID/ FACO <br /> am AMOUNT IMOTTED C"W"tCAAM RECEIVED By GATE FOR ITANINIVACE REQUEST NJ"M INVOICE <br /> d . Ddo <br /> `p <br /> ot�0 �#�PEpD <br />