Laserfiche WebLink
I <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> (! V NOR-REFUIIDABL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> OV <br /> f' :1 (Complfh In TIIpnmeel . <br /> APPUC/11I11N 19 HERE By MADE TO THE SAN JOAQUIN COtWTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAL-THE WOW OESCMSED.TIOQ APPLICATION IB MADE IN COMPL <br /> JOAOUIN COUNTY DEVELOPMENT TFtLE,CNAPFEFI 9-11115.3 ANOTHE STANDARDS OF SAN JOAOLIIN COUNTY PIRSI.IC HEALTH SERVK:EB,ENVIRONMENTAL HEALTH OMBbNIANCE WRIT SAN <br /> , •,I <br /> Iti <br /> JOB AbO1RE99ro111 APNr � p�7 crcv R�9 !1/ /y PARCEL elzErArNr <br /> OWNER'S NAME C Ir) N' 4,4F <br /> ADORERS �p1 MIO I <br /> NE U 7S <br /> CONTRACTOR ADOREGO <br /> :I <br /> LPCr' PHONE r <br /> RVB CONTRACTOR ADDRESS LCI P1bNE a <br /> P <br /> TYPE.QF WELL ptl/JIP: ❑ NEW YVELI i� CICEMENT WELL © TOFVNA WELL I (3 OTHER <br /> � 11INSTALLAT.N LL SYSTEM REPAIR CRODS-0ONNNECT REPAIR <br /> �n{� ❑ VAPgq E%Tf1/4CT10H WELL r <br /> 13Nsw"'g^°P N.P" DEPTH PUMP 8ET FT. FIRST WATER LEVEL <br /> II m OF PUMPI y O <br /> {I :I ❑ OUT-0F•SERVICE WELL ❑OEORIYSICAL WELL/ ❑ SOIL Noma .I S <br /> ❑DESTRUCTION: ., <br /> �i <br /> 'r <br /> INTENDED USE TYPE CO iTRUCTIO fFECIFIC IONf A <br /> ❑ IND IUBTRMAL Eropm BOTTOM DIA.OF WELL EXCAVATION DA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICISygVATE ❑a AVEL PACK/SIZE TYPE OF CASIHO19TfftffmC DIA,OF WELL CASINO Q <br /> .❑..��PUBLICIMUNICIPAL ❑DRIVEN' DEPTH OF GROUT SEAL SPECIFICATroN i a <br /> L�7'fRPoOATbNlAO ❑OTHER, <br /> GROUT REAL INSTALLED By GROUT BRAND NAME JE <br /> ❑ MOWTORI140 OROUT SEAL PUMPED: ❑Yea ❑Na CONCRETE PEDESTAL gY GRILLER:❑YM ❑Na g <br /> ArpmOX.Owl" LOCKINGCHEOTERSDXMGVE PIPE <br /> PROPOSED CONeTgUCT10NIbISLLlN4 METHOD: MUD ROTARY AIR ROTARY .AUGEq CABLE OTHER . <br /> I HE9ESY CtMI Y THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOFML WILLpE DONE IN ACCORDANCE WITH <br /> CAN JOAOUIRV COUNTY DFROINANCFS,SPATE LAWS,AND RULES AND <br /> RfOL1LATIOHS OF TIIE AN JOAQUIN COUNTY. HO R OR LICENSED AOENT'S 8101NATURE CERTIFIED THE FOLLOW1NO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WlpCH <br /> THIS PERMIT IS tBSU T EMPLOY PE JECT TO WORI(MAN18 COMPENSATION LAWS OF CALIFOFHIA,• CONTRACTOR'S WRING OR SU"ONTRACTINO SMNATURE CERTIFIES <br /> TIIE FOLLOVMM: IFY AT IN TFIE ANCE OF THE WO1Mt FOR WHICH THIS PERMPT IV ISOM,I SHALL EMPLOY PERSONS SUBJECT TO WOMMAN'i COMPMOATION LAWS OF i <br /> CALIFORNIA.' A MUST C IN ADVANCE FON ALL REQUIRED IIIePSCT10NS AT 1"01400.9423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> I€SIo�d X I� TRI• <br /> E I; PLOT PLAN lovow to gealal SaaH •is <br /> 1,;NAMES OF STREETS OR RIQADR NEAREST TO OR 0OUNDOM TIIE PROPERTY, 4, LOCATION OF HOUSE SEWAGE D19MM SYSTEM OR 1'flPi'OBEO <br /> Z.OUTLINE OF THE I710PERTtY,pTVII10 DIMENSaTNB Am NORTN OIIIECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AM LOCATION OF ALL EXIStom AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE MM-- <br /> STRUCTURES, FUFTY FP. <br /> STRUCTURES,MLUDIFM COVERED AREAS OWN AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJO1NONfl PROPERTY. <br /> • <br /> .i. :.- .....E ..i.. .. <br /> II <br /> " APR_: i99$ <br /> - <br /> y„ x hrtic6ul'ay <br /> ii <br /> DEPARTMENT LMB ONLY <br /> 4 lam` <br /> Aappcatlen Aeaepled By OHS 11-7 <br /> 16M <br /> n—A t-peatlan By P bete PImP Impaction BY vote <br /> I� I <br /> D.,.tr.ratMn Impeedon By I� <br /> Data <br /> !I J <br /> rarnmara�: 1 <br /> ;{ <br /> J M <br /> [�'' 4-{ <br /> ACCOUNTIHR ONLY: AIb! FACT <br /> 4E CODES FEE INFO AMOUNT REMITTED C C A8H RECEIVED fY DATE "mmTlSml;ICE REQUEST NUM86�t INVOICE ' <br /> D5 p r60'00 LPA q <br /> ;i <br /> Pub wealth Sem-ErpArQ.173(1197) � <br />