SU0006497 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL/PUMP PERMIT /� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 6Z� S t \ ENVIRONMENTAL HEALTH DIVISION A 304 EAST WEBER AVENUE, STOCKTON, CA 95202 \ (209) 468-3420 \\ RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compute In TTIpDental APPLICATION IS HERE BY MADE TO THE SAN JOAODIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMRIANCE WITH SAN JOAOUIN COUNTY DEVELO[M�ENTT TITU.CHAFFER 9-11115..3,JAND THE STANDARDS OF SAN"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB AODRESSMR AMI I-Z }' (� �Ji J.A Tf�!_� trr({ CRY ♦ s w PARCEL SIZE/APNI OWNER'6 NAME�)�GCiJ A ADDRESS � _ PHONE COMMCTORiAMlEBef2Qj/Co S&_ UC01 264PHOI NE <� I OUR CONTRACTOR ADDRESS me RHONE I TYPE OFWLLURUMP ❑ NEW WELL ❑ RPLACEMELR WELL ❑ MONRORNO WELL I ❑ OTHER o ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL I J ❑NE.Y❑RSPW H.P. � DEPTH RUMP SET3—y—R. FIRM WATERLEVEL O R YFE OF PUMPI ❑ OUT-0FBEIVK:E WELL ❑ GEOPHYSICAL WELL I ❑ SOHL BORING 6 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ WRPE 1INSTAL ❑ON BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D —0rmMESTIC/P0VATE ❑GROVEL PACRISRE TYPE OF CASINGRTEELMVC DIA.OF WELL CASINO D ❑ MBLICrMUNICIPAL ❑NNXVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRROATION/AO ❑OTHER GROW 6EAL INSTALLED BY BMW RRANO NAME E ❑ MONITORING .. //// OMUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY ORLLFR:❑Ym CIN* 5 APPROX.DEPTH— l0 LOCKING CHESTER BOXIMOW RPE S RGMSFO CONSTRUGTONRNSLLIN METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE m ACCORDANCE WITH BAN"AWN COUNTY OMINANCES.STATE LAWS.AND RULES AN; REGULATIONS OF THE BAN JOAOUN COUNTY. HOME OWNER OR LICENSED AGENT'S SMNAT VINE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFOPo./ANCE OF THE WORK FOR WHICH TMS KNOUT IB ISSUED,I MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATOR LAWS OF CALIFORMA.' CONTRACTOR'S HIRHO OR SUBCONTRACTBG SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT N THE PERFORMANCE OF THE WORK MR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY KIMONO$U"CT TO WOIIKMIIN't COMKNSAT IN LAWS OF CAUFORMA.- 1 APPUCAMT MUST CALL SS HOURS IM ADVANCE FOR ALL REOWED IN�rSSI^I NOTIONS AT MOSI 4411410123. M 123. COMPLETE DRIVING AT LOWER AREA PROVIDED. v 7� S.,,—i X o S TIMI pl- A V.I. KOT PAN ON.Ie 8E1.1 SeFIS le �� 1, NAMES OF STREETS OR MMS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR FRoMSED ee—S lV 3. OUTLINE OF THE PIIOPLRTY.GIVING DHMENSGNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. V J. DIMENSGNED OMMFB AND LOCATION OF ALL EXIBTNO AND PROM$EO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO$,DRIVEWAYS,ANSI WALKS. ON THE PROPERTY OR ADJOINING WKIPFMY. w Al p 6� s� S FEB 41999 . .._ SAN JOAQUIN COUNT� >USLJC 1FALTH SERVICED .NvNRONMENTAL HEAISH OIVISIOM1 EPMTMENT USE BODY neelloelen A«apHM SY � � DF• !� � MeI�� al.,O IrwP«Ileo BY DOW RmF MN Sart BY OHS�ZL� D..I„sn..,IrRe«filen Rr Ge. 71I�Ne oo PY ACCOUNTING ONLY: NDI FACT PE COD” FEE INFO AMOUNT"EMITTED CHECKI ASN AECDVED■Y DATE PERMITISERVICE REQUEST MU VISOR INVOICE Pub IHeallh Serv.-Enviro.173(1/97)