Laserfiche WebLink
•SAN APPLICATION FOR VVELLIPUMP PERMIT • GI Z I n <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388 ,ENVIRONMENTAL <br /> WEBER AVENUE, STOCKTON. CA SMI- 88 <br /> (209) 463-3420 <br /> MOM-REFUNDABLE PERMIT ERPIRES 1 YEAR FROM DATE ISSUED <br /> ICOMI <br /> APPLICATION IB IIERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTIA O/Oq INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE VAIN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICENVIRONMENTAL HEALTH DIVISION.ES <br /> JOB ADDRE891OR AM, ,EN <br /> / <br /> OWNER'S NAME C TU PARCE"I E/,LpN0 -) <br /> ADORES _ 1 /qeVl <br /> CONTRACTOR PHONE <br /> ADDAE86ti/ CI U <br /> BUB COMRACTOLA <br /> I • ^1.��jSNE�u,- TZI <br /> ADDRESS 1 � R1aNF�i�YNF. Qz'1 <br /> TYPE OF WFLL/PUMP ❑ NEW WELL ❑ RFPACEMENT WELL <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ MONITORING WELL A IJ OTHER <br /> 11Naw❑ ❑ CROSS-CONNECT REPAIR <br /> 11 VAPOR EXTRACTION WELL/ <br /> ITYPE OF UMPI R.pdt H.P, DEPTH UMP SET J <br /> �R• FIRST WATER LEVEL <br /> ❑ OVT-OP SERVICE WELL ❑ GEOPIYBICAL WELL I <br /> ❑DESTRUCTION: BOIL BOMNO <br /> B <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATION! <br /> ❑ <br /> INDUSTRIAL ❑OPEN BOTTOM <br /> ❑ DOMEBTICTRIVATE ❑GRAVEL PACKMIZE DIA.OF WELL EXCAVATION A <br /> DIA.OF CONDUCTOR CASINO-- <br /> 11 UBUC/MVNlCIPgL ❑ONVEN TYPE OF CABINOIBtEEIUPVCD <br /> _ <br /> DEPTH OF OFOUT SEAL DIA.OF WELL CASINO -- <br /> 13IRRIGATgN/AG 11 OTHER SPECIFICATION <br /> ❑ MONHONNO GROUT SEAL INSTALLED By_ E R <br /> PEO: ❑yr ❑ GROW BRAND NAME--- <br /> APPROX.X.DEPTH GROUT SEAL UM <br /> `T� CONCHETE PEDESTAL BY DNLLER:❑yti [IN. 5 <br /> MOPOSM CONSTRUCEN""OIELUNG METHOD: MUD ROTARY LOCKING CHEWERBO E PIPE <br /> AIfl ROTARY AUGER <br /> R <br /> CABLE OTHER <br /> lf <br /> I HEAEBV CERTIFY THAT I JOAQUIN <br /> COU TNIB APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCOUANCE PATH BAN JOAOUIN COUNTY pRDINANCEB.SLATE DWS,AND PULES AND <br /> REGLAD OF THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING.'I CEIAIFY THAT M THE PERFORMANCE E THE ,ANL FOR WHICH <br /> T RMIT IS UFO,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWg OF CALIFORNIA.- C. I CEMI THAT NO OR RUB- <br /> E FOLLOWING: •1 CERTIFY THAT IN THE PERF SMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT N I WORKMAN'S INO SIG COMPENSATION AWB OF <br /> C FORNIA.- T APPLICANT MUST LL-24 URS ADVANCE FOR ALL REOUREV INSR/E/C{7�HONS AT 11D11 IpJE]S, COMPLETE DRAWING AT LOWER AREA PSC OMPONAT IO LAWS r <br /> Me, <br /> Bloned% ,_[ / q <br /> TUR. Do._ <br /> 1. NAMES OF STREETS Oq ROADS N eT TO OR BOUNI. <br /> DING PLOT THE PROPERTY. Bele <br /> I. <br /> FT1 <br /> 3. DIMENBIONED O2 OUTLINE OF EVfLINEB A.01"LOCATION EOF ONSALL AND <br /> OANp PgOPoeN. A' LOCATION OF HOUSE SEWAGE DRIMBAL SYSTEM Ofl PROIOSED <br /> STRUCTURES,INCLUDING COVEREb AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. LOCATbN OF WELLS WItHtN RADIUS OF ONE NUNOIIEO FIFTY FT. <br /> . _ ON TIIE PROPERTY Ofl ADJOINING PROPERTY, <br /> AN <br /> 0 Y\c'µ1 <br /> O <br /> o O <br /> i <br /> ,1y/�E)� ' / ,I , / — DEPARTMENT USE ONLY <br /> Applie.tlen Aceepw my_ <br /> 1"I"". ; 1 - 'IAYhL��I,. >�/1f <br /> G'.el lmoep,bn BY / I (ta Mu <br /> O.M Pump Impevgen By <br /> Dalnmlbn M1xPy'Ibn gY D.M1 <br /> Cemmem.: <br /> Do. <br /> ACCOUNTINO ONLY: AID! o <br /> FAC! <br /> PE COVES FEE INFO AMOUNT REAUTTED CHECKI/VASN RECEIVED SY DATE <br /> OO PE/IAIITISFRWCE REOUESj NUMBER INVOICE <br /> o <br /> Pub.Health Serv.-ERvl,.173(3/96) <br />