FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L/ ENVIRONMENTAL HEALTH DIVISION \um", P.O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 1209►468-3410 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Co leto sial APPLICATION IR HERE BY MADE TO THE RAN JOAOUIN COUNTY fon A FfnMIT TO COATS PnUCTIAND/on INRTALL INE WOPK DERCnim).THIP AMICATION IR MADE IN COMPLIANCE WITII SAN JOAOUIN COUNTY DEVEIOFMENT TITLE,CHAPTER 9-1115.3 AND TIIE STANDAnbS OF SAN JOAOUIN COUNTY RIBUC HEALTH SEnVICES,ENVInONMENTAL HEALTH OMSION. JOB ADDRERR/OR APN/..159O W, C da He r1 / c7+lJC.k�.pfl PAI10El RIZE/ARU ewNEn'a NAME M fi r O u F DA: If MDnEBa� 3 YQ W G NO f0 r V& CONFMCTOR_j-/[1L1fl(Y a-c+n /LL� e.n �/IA4 ADMIERRQ3 L,�/, Y�A! UCI F L1S�L p QZZ RIONF/.gs LgZhj SUB CONTRACTOR `r /t &t.1411-7 71 AnD"FIMM/5 !` /,11�L-OMT UC/ �fRL'Z`Z RbNYE/+qQ PE OF WELUPIMPI ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL t yq OTHER p rQn 1172 �.�.•� ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT nFPAln ❑VAPOR EXTRACTION WELL/ ❑N«v❑ J IMpdr 11-P• DEPTH PUMP NET FT. i111ST WATER LEVEL _ H YI`E OF PUMP) O ❑OUT-OF-SERVICE WELL 11 OEOPIYRICAL WELL/ ROIL BOItINO Z S DESTIRICTION: _ NIEMbED UEE TYPE OF WE CONS IRUC110N iPECIFICAl10N! _ 11R7DLISTIBAL ❑OPEN Bottom DIA.Of WFLL EXCAVATION_ I J Z DIA.OF CONDUCTOR CARIIIO AV A 11 0 9OMP9IIOII'1tlVATE ❑nnAVFI-PACK/M7f. TVIY M f.ARINR/R1ffITw.T�j� h DIA.Of WFI I.CASING ti n ❑-TT PURLWIMUNICR•AL ❑nIRVTN nFP1N Of nAnNI FEAT. BIYCIfICATION 11 StRIGATION/AO ❑omEn -{� p R OnOUT SEAL INSTALLED RY T/cf Ad f 1/ OnOUT BRAND NAME 'I G J yyylfjhE ®MOMTOPUNG On011T SFAI.PIMPED:(:1 Y.. ®N• T- CONCRETE PEDESTAL BY DRILLER: ►Yr ❑Nn S �' p APPRO K.DEPTH LOCKINO CIMSTEn BOX/RTOVE RPE V/, S PROPOSED CON$TRUCTION/DIOLUNO METHOD: MUD ILOTAIIY Aln nOTHER OTARY ALMER CARLE p- Q I NMRY CERTIFY THAT I HAVE PREPARED TIIIR AITUCATION AND THAT TIIE Wow WILL BE DONE IN ACCOnDANCE WITH SAN JOAOUIN COUNTY OMINANCES,RTATE IAWR,AND RALES AND nEOU AT10N8 OF THE SAN JOAOUtN COUNTY,HOME OWNER On L/CENRED AGENT'S SIGNATURE CERTIFIES THE roUamNO:'1 CEIITIFV iNA7 BJ T{IE FFIKORMANCE OF THE WORK fOR YVIAND tIRR PERMIT la IBRUED,1 SHALL NOT EMPLOY PERRON"SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUr0r 1A.'CONTMCTOR'6 WINO OR FTWO"SUN M"CE OF SIGNATURE CERHf1Ea THE FOLLOWING: 'i CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOS WHICH TIIIR PERMIT IR ISBVED,1 R/IALL EMPLOY PEnSONR M/BJFCT TO WORKMAN'S COMPFNtATION LAWS OF CALNOnMA.' THE APPLICANT MUST CALL 31 HOURS IN ADVANCE fOR ALL AE01111Rfn INSPECTION$AT Itttl 4St-SSSS,COMPLETE bMWNJO AT LOWER AREA PROVIDED. l n /K$..r/x iM'L ?-• y TPR. S44FF GPoIo I � PLOT PLAN Nre'er I.Sao.)Re.l. •1. 1.NAMFA of RInF.EfB On IIDADS MARERT TO On ROUNDING TNf RK1FfnTY. �,LOCATION OF IIOURF.STWAOE OtR10RAl$YRT F.M On 1'nOi`L16Eo 1.OUTLNIE OF TIIE P OFFRfy,OIVWO DIMENSIONS AND NORTH DIRECTION. EKPANSONION OF SEWAGE WAOFDlgr'OAI SYRIEMS. 3.DRAFNRPONEO OUTLINES AND LOCATION OF ALL EXIRTINO AND PROPOSED a.LOCATION OF WELLS WITHIN MM11S aT ONE IIVNDRED HRV FT. STRUCTURES,INCLUDING COVERED AREAS SUCH A$PATIOS,OPPIEWAYS,AND WALKS. ON THE ON OP WE LS ADJOINING PIOPFIHH y. .. .. :. :. .. .vim .. WpQK f/cov Da+ z5 ©r+abe� i AOFPMTMENT USE'ONLY APPR.NI.n .•.piwl BY bN• /L/ U Au Oreul IMP..IIen by b.t. 14nP ImP..Iien RF ON• b..lnntbn Irn...11.n BY D.1. C.mmenl.: ACCOUNTING ONLY: AIDS FAC/ PE CODES FEE$NFO AM TTREMITTED CHE /CA$H RECDVEO BY DATE PETMIT/tEn"CE REQUEST NUMaM INVOICE Pub.Heafth Serv.-Enviro.173(3196)