Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT! <br /> SAN JOAODIN COUNTY PUBLIC HEALTH SERvICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P•O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO ' <br /> (Co1RpI�U <br /> in TI}111cdA <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN CO <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-7115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLI/OMPLIANCE WRIT SAN <br /> C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.IZE/APNI <br /> JOB ADDRE69A AM. ` PARCEL B1 <br /> / �L�rr <br /> OVRlER'8 NAMEADDRESS <br /> CONTRACTOR�J' 7A�)�-���Sf�L`MRs/L♦� f/ P .v� �lrJ� iCIG(/� <br /> PHOONN E I I7 <br /> SUB CONTRACTOR ADDRESC UC <br /> PHONE <br /> TYPE OF WELL/PUMP: RrNE.WELL ❑REPLACEMENT WELL C7 MONITORING WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CnOSS-CONNECT TIEPAIR ❑VAPOR E%TRACTION WELL I <br /> HYPE OF PUMP) <br /> ❑Neve❑Ft P.11 H.P. DEPTH PRIMP SET FT. FIRST TER LEVEL O I <br /> -- <br /> ❑OUT-OP SERVICE WELL 11GEOPI IYGICAL WELL I SOIL BORING 8 ! <br /> 11 DESTRUCTION! <br /> INTENDED UFE TYPE OF WELL CONFTRVCiION 6PECIFIChTIONF <br /> 11 INDUSTRIAL El OPEN BOTTOM ��♦♦ 9 <br /> DIA.OF WELL EXCAVATION iN � DIA.OF CONO VCTOR CASING #914 <br /> 9 l/]�` 0 <br /> ❑DOMESTIC/PnvvATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEI��- DIA.OF WELL CASINO 't ff <br /> ❑PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL w1 SPECIFICATION N•�� R {E <br /> ❑IROIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROIfT BRAND NAME „, t <br /> L�L•I/ <br /> MONITORING GROUT SEAL PVMPEO;❑Yo. Cha CONCRETE PEDESTAL BY DRILLER:❑Y—' LINO <br /> 35' s i <br /> APPROX.pEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PFQPOSFD CONSTRUCTIONIDRILUNO METHOD: MUD BOTAM AIR ROTARY AUGER L/ CAflLE OTHER_0� <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL DE DONE IN ACCORDANCE WITH FAN JOAQUIN COUNN ORDINANCES,STATE LAWO,AND RUlE6 AND <br /> REGULATIONS Of THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERT IFIE6 THE FOLLOWING:"i CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FORE <br /> OR WHICH THIS PERMIT I6 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIBINO OR PUB-CONTMCTING SIGNATURE CFiRIFIE6 <br /> TIIE FOLLOWING: 'I CEITFIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY FER60N8 SUBJECT TO WORKMAN'S COMI`EItM UBE LAWS OF <br /> CALIFORNIA.' TH T%UST CM.L N ADVANCE FOR ALL PEOUnlo INIrFCTiONI T 120-)/0IJd22,COMPLETE DRAWING AT LOWER AREA PRtOVIDED. <br /> 810rv-0% ��l? "r J TIII. �Q�.CLD.t <br /> T /V X77 <br /> PLOT PLAN(0—to SONO SO.Ie "to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. S.LOCATION OF HOUSESEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2.OUT UNE OF THE PROPERTY,GRAND DIMENSIONS AND NORTH DIRECTION. E%PANFfON OF SEWAGE DISPOSAL SYSTEMS. <br /> D.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS GUC1{AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY <br /> I <br /> .. .. ....i .. ... - <br /> �nI DEPARTMENT UDE <br /> APPliullen Aeve, PY 'J� � I •^1•�1y y/� bele ��"'1�; <br /> QIOVI In.Paellon DY. D.te l� !//-I 1 R�mn In.n..;,i,.n n I M�D.tI <br /> Oe•In�elian Irn Pachon By <br /> b.c <br /> 1 <br /> Commpn.: <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CAS!{ RECEIVED BY DE PERMIT/SERVICE REQUEST NUMBER—AT INVOICE <br /> c 012 s <br /> Pub.Health Serv.-Enviro.173(3/96) <br /> t <br />