Laserfiche WebLink
' I ( -, P <-"T 7 P e, �-a-.e' {Compbt6 in Tripliatrl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUI COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT T;TLE, APTO 9 11 AND TANDARDS OF SAN JOAQUIN COUNTY PUNC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN#! (II CITY J ' PARCEL SAZFJAPH <br /> ' OWNER'S NAME I 0 ADDRESS <br /> CONTRACTOR •YL, ADDRESS UcBr,, _PHONE V-2o&1 <br /> SUB CONTRACTOR ADDRESS UCrr PHONEY <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ f EPLACEMENT WELL ❑ M! WELL d ❑ OTHER <br /> ❑ INSTALLATION ❑V VELL SYSTEM REPAIR Lid CROSS-CONNECT REPAIR ® VAPOR EXTRACTION WELL* J <br /> 1 ® <br /> New❑Repel, H.P. DEPTH PUMPSE•T FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP( <br /> ❑ UT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL" ❑ SOIL HOSING B <br /> r <br /> ' ❑DESTRUCTION: a• <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ® INDUSTRIAL ❑OPEN BOTTOM I DIA.OF WELL EXCAVATION __ DIA.OF CONDUCTOR CASING D <br /> ® DOMESTICIPRIVATE ❑GRAVEL PACK1SlZE TYPE OF CASING/STEELJPVC DiA.OF WELL CASING D <br /> zn <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ® IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME _ ^. E <br /> ® MoNITORING GROUT SEAL PUMPED: ❑Yea ❑Na CONCRETE PEDESTAL BV DRILLER:❑lf,- ®Ne S' {(p` <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE <br /> PROPOSED CONSTRUCTIONICRILLING METTNOD: MU ROTARY AIR ROTARY AUGER__CABLE OTHER <br /> L HECIEBY CERTIFY THAT I HAVE PREPARED THIS IO <br /> CATN AND THAT THE WORK WAN ILL BE DONE IN ACCORDANCE V4ITH SJOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> ' REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSOP S SUBJECT TO WORKMAN'S COMPEN6ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING ORSUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "I CERTIFY THAT IN THE RFO ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." Tiff CANT MUST C NO AN ADVANCE FOR ALL REGLRMM INBPEC AT 12WI 466-5429. COMPLETE DRAWING AT LOWER AREA PROVIDED. ^��9+ <br /> SYpnmd X Tile ,, ' -- — Dace !�� �D <br /> ' T IDrwv to Sealal Sale <br /> 1. NAMES F STREETS OR ROADS NEAREST TO OR UNDI HE PRtOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS O NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 9. DIMENSIONED OUTLINES AND LOCATION OF ALL E (STING AND PROPOSED H. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ' <br /> STRUCTURES,INCLUDING COVERED AREAS SUCHS PATIOS,DRIVEWAYS,AND WALKS. <br /> UN THE PROPERTY OR ADJOINING PROPERTY. <br /> ... ................�........................n...... ........ ........ ..... ....... .. , <br /> .... .... <br /> .... , <br /> 1 ..'.. ..... ...... ......... .. .. . . .. .. <br /> : <br /> ... <br /> ............ _... ... ......... <br /> ... ....v ... <br /> .. ..... ....................... <br /> ...v.. ...:... <br /> ................... ........ ... ... ..................... .. .............. .... y <br /> . . . . : . . . • ........ ,... i.....o... ). ,...... <br /> .. _ <br /> 04 <br /> .: .. . I <br /> 1� <br /> DEPARTMENT USE ONLY <br /> :iAppllcation Accwt.d By® F ®` Date <br /> Gout Inspacticn By^ Det.• Pump Impaction By .Date ; <br /> ' Destruction Impaction By Dat. <br /> Commenter.+ '� _ <br />