Laserfiche WebLink
APPLICATION FOR WELL/PUMP 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 /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ��� (ComPletB In TIIPReEtEI <br /> APPLICATION IS HERE BY MAGE HE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AN <br /> UgR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WHIZ SAN <br /> JOAQUIN COUNTY DEVELOMEE LE,CRrAMER 9-1116.7 AND THE STANDARDS OF BAN"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J08 ADHRE88AOfl APNI �/G35 /Vl�4/1 ..✓)✓k�L�-%�/$ CITY PARCEL BIZEIARII <br /> OWNER'S NAME//ff ,1 ADORE88 G�L/��L, ,.1I'�7�?(cC/J ryryry,,,��� PHONE/ ��\J/l <br /> COMRACTOR_/`Y�/)'TINCT. �t-U � ADTMEBBt�yl//�� //��/{l/L�Jf'\�I6,1 UC/�IRIONE/ /t,(JICI <br /> BOB CONTRACTOR Appf1E8BJ /VL�IU� 1 L/CI R10NE0 <br /> TYPE OF MLL/PUMP• ❑ NEW WELL ❑ REPLACEMENT WELL Jury MONITORING WELL I ❑ OTHER <br /> 11INSTALLATION 11WELL SYSTEM REPAIR ❑ CROS$-CONNECT REPAIR 13 VAPOR EXTRACTION WELL I <br /> HYPL OF PLIMPI <br /> ❑N.w❑R.AW N.P. DEPTH MMP BET FT. FIRST WATER LEVEL V <br /> ❑ OUT-OF-SERVICE WELL ❑ OwFINYSICAL WELL/ Er—.OIL BORING S <br /> ❑DESTRUCTION: <br /> INTNMDED ULE TYPE OF WELL CONOMMUON{PECIFICATIONE (� PA- <br /> C] <br /> 1 A <br /> ❑ <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION 2� QI/ VIA.OF CONDUCTOR CASINO��T /�'A O <br /> ❑ DOMESTgTWVATE C1 GRAVEL PACK/m2E TYPE OF CARIMATEE G DIA.OF WELL CASING of(A p <br /> ❑ PUBLN:MUNICIPAL E❑DDMWN �_(���^non DEPTH OF OROUT SEAL <br /> SPECIFICATION /� A <br /> .❑1IIRROATIONIAO C1OTHER '�(�1/�JCi" GROUT REAL INSTALLED BY ✓I � E-� GROUT BRAND NAME ��,C.�� F <br /> AOS.DI HO �D / GROUT SEAL PUMPED: ❑Vr CONCRETE PEDESTAL BY DRILLER:❑Yr CIN* 5 <br /> APRIOX.pEITH LOCKING CHESTEn BOXISTOVE RPE S <br /> PROPOSED CONSMMTIONT LUNO METHOD: MUD ROTARY AIR ROTARY AMER C OTHER 1. A✓'/�F <br /> I HEREBY CERTIFY T14AT I HAVE PREPARED THIS AFRIOATION AND THAT THE W VW WALL BE DONE N ACCORDANCE WITH BAN"AMIN COUNTV ORGINAMES,STATE DWS,AND R,,,ANO <br /> PEOULATIONS OF THE BAN JOAOUIN COUNTY. ROME OWNER OR LICENSED AGENT-0 SIGNATURE CERTEIES THE FOLLOWING:•1 CERTIFY THAT N THE RRFOBMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 18188UE0,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORILMAN'B COMMUNISATION LAWS OF CALIFORNIA.- CONTMCTOR'B(BRING OR BU"ONTRACTNG SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT N TIIE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.* THE AFRICANT MUST <br /> /CI/ALLLL 22`D4/]yMISH,IN ADVANCE FOR ALL REOUmw IN2m311 NN4 yA/T LM N 400 S22. COMPLETE DRAWING AT LOWER AREA OVIO O. <br /> SISe.i X '®V- 4 —.�.YiT M! 1 Till. <br /> ROT RAR 0.1.B..I.1 6..1. •lero TV'f <br /> 1. NAMES OF STREETS OR ROADS WAFWBT TO OR BOUNDING THE RgMM. d <br /> �, LOCATION OF MUSE SEWAGE BPOSAL SYSTEM OR PiIOI'OBFD <br /> 2. OMUR/E OF THE FNUMURTY,GRAM DIMENSIONS AND MFGH QUECTMN. EXPANSION OF SEWAGE dAGE m ST <br /> SYEMS. <br /> S. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXIST"AND PROM ED S. LOCATION OF WELLS WHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTm1CTVflE8,MUGGING COVERED AREAS BUNCH AS PATIOS,DRIVEWAYS,ANO WAIS. ON THE PROPERTY OR ADANNNO FROMM. <br /> DEFMTMMT USE ONLY <br /> nPPnrllen AavTld BT `�L'G7/L/Y'G '�li D.I. /O-_y— <br /> Grein IMP«Ileo ev Dm Pvne ImvmBen BY O.I. <br /> De.N,RBeR I,wn«Ileo Br �.w4C'i 5 �-I� 1, J p <br /> o.I. V /r» <br /> ACCOUNTING ONLY: Aq/ PACE <br /> PF CODES FEE INFO AMOUNT REMITTED CHECKIMASH RECEIVED BY DATE PA T/SERVICE REQUEST NUMBER INVOICE <br /> 3701 e� ao �Zio to 9q •1 S <br /> Pub Health Serv.-Enviro.173(1/97) <br />