Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> 3 <br /> JOAQUIN.COUNTY OUBLIC HEALTH SERYIL_ ' <br /> - ENVIRONMENTAL HEALTH DIVISION <br /> ""- ,,.,P#O,80X 388,304 EAST Wr:BER AVBNUE:, STOCKTON, CA 9520t'w <br /> 099) 488.2420 <br /> �.d 3 zs� k <br /> O11�REFURUABLE PERMIT EXPIRES I PEAR FROM DATE ISSUED <br /> t (Centplete In 10ptielt6} <br /> AM'!'LICATION 18 iIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR 14 PERMIT TO CONSTRUCT ANOMIC INSTALL THE WORK DESCRIBED.71118 APPLICA710H 19 MADE IN COMPLIANCE 1A11411 SAM x' <br />+ JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0.1119,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEALTIISEERVICE@.ENVIRONMENTAL HEALTH DIVIBION. J 14 _ <br /> JOB ADOREGOMA APR# Al CITY / <br /> �fjJ �/ 1� - 7—�—•� PAROL SIZE(APNB <br /> f OWNER'@ NAME-/fid X IG{„+C _ � L C.L"C <br /> -- - - — ✓�J/G C,f�. <br /> ADORER .� PHONE <br /> CONTRACTOR. � - ` <br /> n .. ,: ADOREBB LICI377?Tf PHONER <br /> BV@ CONTRACTOR_ AbO11EB5 . <br /> •-- UC! PHONETYPE <br /> OF L MP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL R D OTHER <br /> ❑ INSTALLATION +�WELL @Y@TEM REPAIR t-,) CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ��••--yy J <br /> u t]NNvyQ Repdr ' 'H.P.�` DEPTH PUMP8E1' FT, FIRST WATER LEVEL �� "? <br /> -IT-Y-SPE OF PVMPI tl <br /> ❑ OUT-OP-SERVICE WELL ❑ GEOPHYSICAL WELL A <br /> © BOIL 13011110 S ' <br /> ❑bEITTRUCTION: <br /> NTENDED UBE TYPE OF WELLCONlTRIJC ION EP CIFIC ION! "Fe <br /> I� A <br /> LJ INDIi@iRIAI OPEN B077tlM - f' <br /> p1A.OF WELL EXCAVATION DM.OF CONDUCTOR CASINO <br /> ❑ OOMESTIC/MVATS ❑GRAVEL PACKISI;E TYPE OF CASINGISTEEIlF'VC - DIA.OF WELL CASINO, , U - <br /> ❑ Pt18UCIMUNMIPAL ❑DRIVEN <br /> DEI'7fI OF GROUT REAL SPECIFICATION <br /> ` IRROATIONIAG ❑OTHER GROUT @EAt INSTALLED BY OAOVr BRAND NAME _ <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑IVe e <br /> S <br /> APPROX.DEPTH LOCKING CHESTER BOXISIOVE PIPE <br /> 3. <br /> PROPOSED CONSTRt1CT10NlbIBIUNG METNIib: MUD ROTARY��p AIR ROTARY AUGER- CABLE OTHE <br /> I ItE4EBY CERTIFY THAT 1 IfAVE PIIEPAREb THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACC011DANCE WITH SAN JOAQUIN COUNTY DIpIFNANCEB.STATE IAWS,AND RULES Altp `s - <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOEHT'S SIGNATURE CERTIFIEB TIIE FOLLOWING.-'1 CERTIFY THAT 1►1 THE PERr'ORMANCE OF TIE WORK FOR 7NHIC11.,":'•`:'`:.:z <br /> THIS PERMIT IS ISSUED,I @IIALL NOT EMPLOY PERSONS SUBJECT TQ WORKMAN'S COMPENBATION LAW@ OF CALIFORNIA.' COHtRACTOR'@ WIRING OR BUB-CDNTRACTINq 81GIATVRE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN TIIE,PERFORMANCE OF THE WORK FOR WItIC11 fHIB PERMIT.IS i88UEb.I @HALL EMPLOY PERSONS SURJECT TO WORKMAN'e COMPEN�ATIOM.LAWS OF CALIFORNIA.* THE APPUCANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTION@ AT 120014003472, COMPLETE DRAFMNO AT LOWER AREA PROVIDED,. <br /> &A- . „D.I. <br /> PLOT RAN ID.ew_to Sed.!@calm <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TII'E PROPERTY, � <br /> 4. LOCATION OF HOLIGE SEWAGE DIOPOSAL SYSTEM OR PROIgSED, i_sss <br /> 7. OUTLINE OF THE PnoPERTY,OIVINq DIMENSIONS AND IIORt11 DIRECTION. _ W-ANBMON•OF SEWAOE DISPOSAL @YSTEMe, <br /> 7. OIMENBIONED OUTLINE@ AND LOCATION OF ALL EMOTING AND PROPOSED -S. LOCAmm OF WELL@ WITHIN RADIUS OF ONE'HVNOIIEb.FIFTY FT <br /> BTRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAtxa, ON THE PROPERTY OR ADJOININq PROPERTY.. <br /> P <br /> ` 3Y. <br /> kN <br /> ...:,. ' <br /> l d <br /> i <br /> , <br /> I <br /> + <br /> _ .. .. <br /> i <br /> ENVIRaNMI:NTa!_HEALTFi bNISID <;; <br /> ApptlwHen AeeaPlsrl BY pale Arra- <br /> Oroct hrpeellen BY .ec Rime In.Peellert ey <br /> beclnmllen In rvogbn By <br /> b.l• r, <br /> Cemrna�lc: <br /> ACCOUNTING ONLY: FAC+1 <br /> PEC FEE INFO AMOUNT REINITTEb HECK /CAn" RECEIVED ST 'RATE P91MITlSERV10E REOVEST NUMlBi INYtlICE <br /> 3 < <br /> Pub.Health Serv.-Enviro.173(3196) <br />