Laserfiche WebLink
APPLICATION FOR WELWPUMP PERMIT <br /> JOAQUIN COUNTY PUBLIC NIALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ENV{RmijAEN i AL HEALTO 0 90X 888, 446 N. BAN JOAQUIN ST„ STOCKTON, CA 96201.388 <br /> CF ;�1C (209) 488-3420 <br /> 94 NOV 13 P•1 I' '6 RON REFUNOAtLE PERMIT bIPIRE3 t clap FpOM DAYE ISSUED <br /> iC*"IlA1 IN TripsmN) <br /> APPLICATION 1E HERNI$Y MAOE TO THE CAN JOA"COUNTY FOR A PERMfT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.TNS APMJCAMN I*MADE IN COMPLJANCE VWM CAN <br /> JOAGM COUNTY DEVELOPMENT Tj"CHAPTER 9-111 S.3 AND TM STANDARDS OF SAN JOAOUIN COUNTY PUKE HEALTH sERVICEs,ENvwoNMENTAL HEALTH DIVISION. <br /> JON ADORESSIOR APN/ /f3 B G L UC,(Cf/E E/� c o u/L r cm—STOCK a/`l PARCEL SMAPW <br /> i2V/N <br /> oNINc1ro HMLC Aovness Z�77yarl ,fc�iL,N,q�/ .ItyE rte, <br /> CONTRACTOR /-1 E,VTr! ` /z/s�..l'fEE . 2VF/4ONE -'77 <br /> MmCONTWToR j <br /> ADI]t1ESS X H v c f s y�Bt;Ic S 7 �� G 3 rS-7 z 74r 1 <br /> 7w'7 3 O ID <br /> TYPE OF WELLINIL&M 0 NEW W§ C] IAEFLACIwENr WELL ❑ MONRTofm WELL r 0 OTHER. X <br /> 177 ,.TIJ IV WW ❑Wn I.f y4TEM REPAIR ❑CROVS-C wNfcT REPA K ❑VAPOp EX71{ACTim WELL 0 , <br /> ❑NOw❑hlyYrl NJ. DEPTH PUMP Wt FT, FWST WATER p <br /> m-PE OF nJMPI <br /> ❑oVT•OF40m"WELL ❑ OEOPHYBICAL MU I BDL soAAINO 7 bOi'7 r��s !S s <br /> INTENDIED LNiE TYK OPWILC TION SPECWCATTONS A <br /> ❑ INDV>RIIYAL ❑"BOTTOM DIA.OP WELL EXCAVATIOM USA•UP 4VNUUC I ON CASING p <br /> O DDMESTICMEVATE ❑ <br /> GRAVEL FACIV ZE TYPE OF CASINO/BrUVrK Dm OF WELL CASWO p <br /> ❑ rIALIWMIRLILIrII. 11�3O"IVIN ~In UrUMUU1 a?AL SPECIFACATHM R <br /> 13NwOATION/A8 U OTM i 1 GMXff UAL INSTAUAD W GADUT$RAND NAME E <br /> 1]mum oumm i OROUT ZEAL RIIIAFFD, ©Yw ❑NO CONCRETE PEDINTAL CY DRLLER 0 YM [3NA S <br /> Arr�Ox.wo LOCKM CNECTER eoxrsrovE Ri1PE a. <br /> PROPOSM COIF MICTIONIMLLOW MMOD: MND NOTARY AIR ROTARY AUOER CABLE OTHER <br /> I HEiEBV CERTIFY THAT 1 HAVC PMPA{VZ 7100 ArrMJd AT'ION ANO TI IAT TI rE WOM WILL OE DONE IN AOCOMDANOE VATH 4/W JO AOVOv GOUIrT•Y 011DIIIA}ILEti,STATE LAV".MU MULL►AlRJ <br /> REGULATIONS OF TME SAN JOAOM COUNTY, NOME OWNER OR LICENSED Acm'C SIONATufm cERTIFIES THE POLL*"":'I CEMIFV THAT IN TwE iFRFORMAmE OF THE WOW FOR WMCH <br /> TNS PEMI T IS H=XD,1 SHALL MOT EFARDY PUMONS 9UCJECT TO WOROOMAN'/COMPOIIBATION LAWS OF CALIFORNIA,' CON'TRACtoWs Rma OR SLNFCONTRAOTIHO MONATUAE CERTFIES <br /> THE I'OLLgWMfO: 14t;Ri>r'Y THAT "ft FprYpMAL/yVGE Or TM WOM POM WW-M THIS PEHMIT fe*VvkfJ-1 WALL t:1 VWY MMUM WBJECT TO WOMMAN's COMPOWATION LAWS OF <br /> CALJFORMA."M APPLICANT.fi%W CALL 24"OURS WOVANCE FOR ALL ASQUI ID 116911=70ONS AT MM 40044". COW%&"0MWM AT LOWER AREA PMVIDD. . <br /> 1. fIAMEs Of BTPf.ETe OR 110 NEAMIEBT TO VMbVVNU1rIY 1 nul�nf TBI V. �» O. <br /> LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OAMNOI MAENCONi ANO NORTH DLRECMN, EXPANSION OF WWAOE DIBPOCAL BYSTELAS. <br /> J. OWENSIONM OUTUWI AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VRrHIN RADIUS OF ONE HNJNDREO f1Fly FT. <br /> is1 M1%;IUFQs,INL:LUUIHL:LUVGQU AIMAS SUCH AJi FATIOS,ORIVEWAYsr AND WMXs. ON THE MNOM OY OR ADJOMING PROPERTY. <br /> . <br /> v... r <br /> .......V......:......p......1.....4..r...I......L...r........y. <br /> ................r.., .. .. <br /> t I i .L.. .i.....4.. ........... ......:......e......;.....,,..,...;......................y......:....5. ! .. ..... <br /> i... ,r... ..:... :.. . . <br /> i <br /> • I <br /> 1 , <br /> ..r... ......................................}�.. <br /> ...i..�.. ..........l............�... .. ......... <br /> I <br /> DEPARTMENT USE ONLY / <br /> Apple~A"a►nld By v( //�( g Y All L �� <br /> Gf%A Ir.vaoa0n ev <br /> DOWWtMnIrVpwueo SY <br /> oBAB _ !i <br /> Canrrwnb: <br /> ACCOL"Mma ONLY: AID/ FACT <br /> PE COOE1 FAR INFO AMOUNT Rmm$TTm CFRCKOICASH AMOVED LY DATE PWMTN6LYICE Amur Numm tKVOH:E <br /> TOTAL P.02 <br />