Laserfiche WebLink
APPLICATION FOR WELUPUMP lPERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> pig I$ <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202' <br /> (209)468-3420 <br /> �I <br /> MOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CmapMtE In TrlpDca161 ji ` <br /> APPLICATION 49 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL THE WOW UESCFJBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITI?SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-11]111.`3 AND THE STANDAR`DDSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, 1 <br /> JOB AODREBSlOR APN_ bL_ "►'Il EIAGi111'YI t I x _ _ CITY LI PARCEL SIZED .[ <br /> a OWNER'S NAME ADDRESS <br /> CONTRACTOR�Y�'Y(�iT � FJ - .__ADDRESS I Llirl'llpflC]Sk IJI FG_U _ L_RPHONE <br /> 1MSIO <br /> SUB CONTRACTOR ADDRESS ! LICe-720nPHONENW/I <br /> a, <br /> 0-4V V MVI <br /> F <br /> } TOF WELL/PUMP, ❑ NEW WELL 13M <br /> REPLACEENT WELL ❑ MONITORING WELL N '1 �� ❑ OTHER <br /> YPE -:.. <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR j; ❑ VAPOR EXTRACTION WELL 1' J <br /> ❑NSW❑Re1111 H.P. DEPTH PUMP SET FT. �{ FIRST WATER LEVEL O <br /> I. HYPE OF PUMP! <br /> 13OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL Ir SOIL BORING <br /> i <br /> ❑DEBTPVCtroN: <br /> �I <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS �1 -` A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM INA.OF WELL EXCAVATION C DIA,OF CONDUCTOR CASINO A <br /> ❑ OOMESTICIPRIVATE ❑GRAVEL PACKlB17E TYPE OF CASINOIBTEELPPVVCqq�'� Li DIA-OF WELL CASINO O <br /> 11PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF OROUT SEAL O V V SL� t'-SPECIFICATION R <br /> ❑-IRRGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY ..- GROUT BRAND NAME <br /> ❑ MOMTOMNG ! GROUT BEAL PUMPED:IPY. ❑Ne i� CONCRETE PEDESTAL BY DRILLER:If Yr [IN. S <br /> APPROX.DEPT" V .__ ,_ LOCKING CHESTER BOXIBTOVE PIPE �r S <br /> PROPOSED CONSTRUCTIONPDRILUNG METHOD. MUD ROTARY AIR ROTARY AMER !p :h CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT I HAVE PREPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND a <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINOiI'1 CERTIFY THAT IN THE PERDRMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SFfALL NDT EMPLO RBOkS SUBJECT TO WORIMAN'S COMPENSATION LAWS OF CALIFORMA,' CPNfRACTOR'B HIRING OR SUB-CONTRACTMNT SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT M T1 RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERBONB SUBJECT TO WORT MAN'S COMPENSATION LAWS OF <br /> CALIFORNI . HE CANT STURS IN!A E FOR ALL REOUIR S}E� S AT 12"1 409'4422. COMPLETE DRAWING AT LOWER AREA PRO DED. <br /> Cr1 <br /> Sy.,1d X Title .y D1I1 U <br /> PLOT PIAN Mvew to Se I Beeie 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. ,p 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED i <br /> 2. OITTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMB. <br /> Zt <br /> ]. DIMENSIONED OURMIES AND LOCATION OF ALL E%WrM ANO PROPQSEp�+"�.,,�--w.- �..,�--..�-- �. 9, LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT._..�.�-� <br /> '� _ _ STRUCTURES.INCLUDING COVERED AREAS SUCH AS'PATIO8,DRIVEWAVB,�AND WALKS.`y ON THE PROPERTY OR ADJOINING PROPERTY. <br /> yam x <br />