Laserfiche WebLink
•PLICATION FOR WELL/PUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERIES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmBIBM In Trblkusl <br /> APPLICATION 19 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCEWITII SAN <br /> JOAOUIN COUNTY DEVELOPEH,Ef�TRLE.C/11�APE R]9-1115.3 AND THE STANDARDS OF SAN JOAOVIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AOORESU At AM' 14/M2�GJ I1/'/. I� CITY S) - ! PARCEL SlZVAPM y <br /> OWNER.9 NAME/ 1 ADDRESS `� ^ PONE# <br /> CONTRACTOR /"rL A���IY�� L >;i^L� rr�"�+'�A• ,79 AODpEBS IJ LLJ UCl G PON1E/ <br /> PUS CONTRACTOR�J� / l/'4� ' ADORSS;Il m,0�2e N HEI I <br /> TYPE OF WELURJMP. ❑ NEW WELL ❑ RI:FUCEMEM WELI. ❑ MONITORING WELL/ VTNER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSLONNECT REPAIR Cl VAPOR EXTRACTION WELL I J <br /> ❑N«r❑RePMr H.P. DEFT"FUMP BET�R. FIRST WATER LEVEL O <br /> TYPE OF PUMP) <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPrvsICK WELL• SDIL BORmG B <br /> ❑DESTRUCTON: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �T A <br /> ❑ INdJSTRIM. ❑OPEN BOTTOM CIA.OF WELL EXCAVATOR �C L1 DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTtCRIVATE ❑GRAVEL PACIUSRE TYPE OF CASINGMTEELiPVC / dA.OF WELL CASINO O <br /> ❑ PIBL/C/MUNICIPAL ❑DRIVEN OEFTH Of GROUT REAL 7 Tn j SMOMAT10N R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY ✓y'V,&VL GROUT BRAND NAME E <br /> CL106NITORNG <br /> GROUT SEK PUMPED: ❑Y. ❑Ns CONCRETE ROESTK BY DRILLER:❑Y. ❑Ne s <br /> AIMOX.DERV �7 t LOCKING CHESTER SOXISTOVE PPE 3 <br /> PLOFOSED CONSTRLIOTONIDRWMO MFTNOO: MUD ROTARY AIR ROTARYAMER CABLE OTHER <br /> t HEREBY CERTIFY THAT I HAVE PREPARED TMS APPLICATION ANO THAT THE WOK WILL BE GONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,ANO Mug AND <br /> REGULATIONS OF THE SAN JOADURI COUNTY. HOME OWNER OR UCENSFD AGENT'S SONATURE CERTIFIES THE MULOWRIO:*1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK MR WHICH <br /> THIS PERMIT IS ISSUED.I STALL IAT EMPLOY PERSONS SUBJECT TO WORKMAN'S CoMMIATON LAWS OF CAUFOR IA.- CONTRACTOR'S HIRING OR BUSCONTINCTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN TE PERFORMANCE OF THE WoM FOR WHICH THIS PERMIT IS MSUEO.1 SNK EMPLOY PERSONS SUBJECT TO WOIIRMAIPS COMI ERSATION LAWS OF <br /> Y/ //A11IIP1PlCANEI MUEi C M IOW IN ADVANCE MR ALL 11EOUMM IN�NSPNBCTIONS AT IMIN Mtl-fA3X. COMPLETE DRAWING AT LOWER AREA PROVIOEO. <br /> CALIFORNIA.- THS <br /> , TIN. D.I. 5—Z-6—C (1 <br /> BIEn.S X—J..+�b <br /> ROT"Al tu,.vi ro Se.I.I S.N. 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNdNO THE MMITTY. .. LOCATION of HOUSE SEWAGE dmOSK SYSTEM OR PROIgBED <br /> E. OUTLIr1E OF THE PROPERTY,DRAM OIMENBIONS ANA NORTH ONIECTION. EXPANBON OF SEWAGE UISroIK SYSTEMS. <br /> 3. DIMENSIONED OUTUNEB ANO LOCATION OF NL EXISTING ANO Prom"O S. LOCATION OF WELLS WITHIN MAORIS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,INCLUDIM COVERED APFAB BMH AS PATIOS.DRIVEWAYS,AND WA S. ON THE FMKRTY OR ADJOINING PROPERTY. <br /> �d�ZYL <br /> . ... . _ <br /> ` oEfAMmmy use ONLY <br /> A"IHHM A.Id BY C05-Lk `�dMll <br /> GrwA 4wseelbn eT D.I. Pme IMeInM BY D.I. <br /> plwbmHen Irweslbn Br D.b <br /> CemmNe. <br /> ACCOUNTING ONLY: AIDI FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKPICAS I RECGVEO BY DATE P TISFRN CE REQUEST NUMBER INVOICE <br /> S (� <br /> Pub Health Serv.-Em M. 173(1197) <br />