Laserfiche WebLink
APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 /> (Complete In TTIpREate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED,THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 ANID THE STANDARDS OF SAN"AMIN COUNTY PPUBUC HEALTH SERVICER.ENVIRONMENTAL HEALTH OMSION, 'E, <br /> JOB ADDRESSIORL AM. j b /504'141�� CIneNCKAt 1/i U t CITY <br /> p L��TNLTT�t I �L I � J PARCEL SIZEJAPNI �> 0 1)::;L0 <br /> OW'NER'S NAME <br /> ( IIAEi< LJILc{ Nv4fcjut\nl-trk+'LVk Ring ADDRESS Ro` UOR ( FIn1ftvdI RN]NE! /7'�+�D 1b1V <br /> CONTRACTOR • aVd It C Id 6-0 FNVI004I"1141 114 ADDRESS -100� ry_WiiSc.T •Nll� uC/—go)-)-7PHONE/ �T _`O� <br /> SNA CONTRACTOR ADCPESS LIC, PHONE/ <br /> TYPE OF WELI PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONROWNO WELL! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C00S8 ONHECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑RIIP41r H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> RYPE OF PIMP( E1qq �L ')-6! 1' <br /> ❑ OUTOF-SERVIOE WELL ❑ GEOPHYSICAL WELL( Iq SOI(BORINOy� \� B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /l A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA. WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTICIRYVATE T❑Tpl GSAM PAMI812E TYPE OF CA81NOMTEEITVC}. DIA.OF WELL CASINO 0 <br /> ❑ PUBIIOIMUNOIPAL LA4DRIVEN DEPTH OF GROUT SEAL TRA SPECIFICATION 9� 'T { S <br /> C❑CG IRRIAATIONIAO ❑OTHER GROUT SEAL INSTAL IED BY 1TP1y}AEµI HIIt GROUT BRAND NAME ?C'01 CeNt\iLl E <br /> EA MONITOMNO _ ( GROUT SEAL PIMPED: Ely. IXN. CONCP E PEDESTAL BY DPJLLER:❑Yw ®M. 5 <br /> APPROX.DFPTN J 5 LOCNINO CHESTER SO%ATOVE RPE-5 <br /> PROPOSED COMSTRUCTIONIpSWNG METNDG: MUD ROTARY Ain ROtARIV AUGER CARIE OTHER'EIP-C Uf h <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLLCATION AND THAT THE WOW WILL BE DOME M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE8 AND <br /> MOULAMNS OF THE SAN"AMIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTUIES THE FOLLOWMG:'1 CERTIFY THAT IN THE PERFORMANCE OF TINE WORK FOR WHKH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS BVILACT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRNO OR SUR.CONTRACTIHO MNATURE CERTIFIES <br /> THE FOLLOWIM: -1 CERTIFY THAT M TR PERFORMANCE OF THE WORK FOR WNKH THIS PERMIT 18 ISSUED.1 WALL EMPLOY PERSONS SMR CT TO WOROAAN'*COMPFMSADON"We OF <br /> CALIFORNIA <br /> .' THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL MOWED IMSMTIONS[A30 <br /> T 181'60-1422. COMPETE DRAWING AT LOWER AREA PROMED.EO. ma) <br /> EtaSG EC io.zrs r D.I. I.-/-s-"L-I <br /> ROT PAN ON—Ie SC.I.I 8a.1. 'b <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDRIIO THE PROPERTY, A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR{TOI`OSFD <br /> 2. OUTLINE OF THE PROPERTY.GP DIMENWNS AND NORTH DIRECTION, E%PANBONION F SEWAGE THMI RAI SYSTEMSSOFON. <br /> 2. NMEMEnOW0 OUTLNew AND LOCATION OF ALL E%ISTRIO AND PROPOSED *. LOCATION OFWELLSO WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,MLUM"COVERED AREAS SACH AS PATIOS,DRIVEWAYS,AND WAL%S. ON THE PROPERTY OR ADJOINRIO PIDPfRTY. <br /> DEPARTMENT USE ONLY <br /> AePI1..ibn A.ew Br� S D.I. A..a &-'o—0/0 <br /> D.I. (I 0 Rme 1n.Pmllen er Doti.— <br /> D.I. <br /> ACCOUNTING ONLY: ND/ FACT —71 <br /> PE CODES FEE INFO AMOUNT REMITTED CHEcz!�R;AEH RECEIVED SY DATE FERPSTISIERNCE REQUEST NUMBER INVOICE <br />