Laserfiche WebLink
XPPLICATION 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 /> NON-REFUNDABLE PERMIT EXPIRES L YEAR FROM DATE ISSUED <br /> IGmpIELE he TrbNEEIEI <br /> APRICATION 19 11EPE MY MADE TO THE SAN JOAOUIN CMN7Y FOR A PERMIT TO CONSTRUCT ANTIMII INSTALL THE VAN(Eff CR LEO.THIS AMICATION 18 MADE IN COMRIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOMMEEM TITLE,CCMy [RIB-111115.7 AND THE STANDARDS OF SAN"AMIN COUIITV"M HEALTH SERVICES,E"W"EMAL HEALTH DMRION. <br /> JOS AOOIIEBIMR..AM,' /f�SL3/%Q�A�,�. �� CRVgOb/�/Te,,A�14rF PARCEL SQUAME <br /> OWNER'2 NAMFJ��/}') //�/Q� ADDIIERR�y�/ `x/J� Q/ F_�l 9sa.3 i�I PHONE F &2-0ia/ <br /> CONTRACTOR L1CI of 3 rHow I <br /> Y <br /> SIM CONTRACTOR AMOEBA MI PHONE I <br /> TYPEOF WELL/RIMP, ❑ ME'W WRL ❑ REPLACEMEM WELL ❑ MONRORINO WELL I ❑ OTHER <br /> ❑ WSTAtx-Am" 0m SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> S4 � RIN—OmN,W H.P. OEM"PUMP SETT. FIRST WATER LEVEL O <br /> HYPE OF RIMR <br /> ❑ wrT -STl9IOE WELL ❑ OEOMNSICAL WELL I ❑ SOK EORNG S <br /> ❑DESTFI ICTION:_Z ` K.��( J <br /> INTENDED UFE TYPE OF WELL COMSTRUCIIOM SPECIFICATIONS A <br /> ❑ MI"MTAAL El on"BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CARIrq O <br /> Pd MWSTKRRIVATE ❑GRAVEL PACKAGE TYPE OF CASSIOMTFELN "A.OF WELL CASINO O <br /> ❑ PIMUCIMIINICNAL ❑"SVEN DEPTH OF Groh SEAL ST'ECHMAT IN I <br /> ❑ SSLMATIONIAO ❑OTMR GROUT SEAL INSTALLED SY GROW BRAMEI NAME E <br /> ❑ MOMTOIONO Groh SEAL Pl1MR0: ❑Y. 11". CONCIET[PEDESTAL SY OPoILER:❑Y. ❑IN 5 <br /> ARIIOX.DEPTH LDCRRMI CHEWER IOXMTOVE EWE S <br /> RmPOSED COMSTRIIC)IONRlIRl1N0 METHOD: IAUD NOTARY AIR ROTARY AWFR CA —mE OTHER <br /> I HERESY CERTIFY THAT I HAVE MEPAAM TMS AI MATIOH ANO THAT THE WOM WALL BE DOM M ACCOMAHCE WITH SAN"AWIN COUNTY ORDINANCES,SLATE LAWS.ANO RULES AND <br /> RMULATION9 OF THE SAN JOAOU111 COUNTY. HOME OWN%M OR LICENSED AOEM'S SIGNATIFE CERTIFIES THE FOLLOWING:-1 CEWTMY THAT 111 THE PEK010.1ANCE OF TILE WORK MR WHICH <br /> THIS PEMFIT N ISSUED,I MIALL NOT EMROY PERSONS MAPECT TO WORIMAM-S COMPENSATION LAWS Of CALIFORNIA.- COMRACTOR'S MIONO OR SlAMO1TRACTMO MOHATURE CEMIFES <br /> TIM FOLLOWING: 'I CENT"THAT M THE RERFORMANCF OF TM WOR(FOR WHICH THUS KRNITT IS MSUETI,I SHALL EMPLOY PERSONS SUBJECT TO WORIO.IAN'S COQI F I AWON LAWS OF <br /> CALIFORMA.- HIE ARPMCANT MIUST)CALL XA IN ADVANCE FOR ALL RREEMIRM M/SF//$T���D�MS^AT IMSI AM-M 31. COMIlETE OMWIEM AT LOWER AMA PIgVIDED. ^y <br /> MONi X /i'(•.i��C/F�PL�/.f/ � � � TIII.. Y//W <br /> ROT RAN S>..�to 8aJe1 ROSIe 'to <br /> I. NAMES OF STREETS OR ROADS WAREST TO OR BOUII"MO TM PROPERTY. I. LOCATION OF HOUSE SEWAGE"SR'DSAL SYSTFM OR R MsM <br /> ], OMLIHE OF TM MOKRTY,GRAIO"AIENSIONS ANO MONTH"RECTION. EXPANNOM OF SFWAOE DMIMI AL SYSTEMS, <br /> ]. "MENNOWD OMT~6 ANO LOCATR]N OF ALL EMRINO ANO PROPOSED E. LOCATION OF WELLS WITHIN M"UB OF ONE HUN"ED TIFEY FT. <br /> STRMMRES,RCLU"NO COVETED AREAS NIGH AS PATIOS,DRIVEWAYS.AND WAU(S. ON TM PROPERTY OR AOJO"RIO RIORg1Y'. <br /> ouy� Wim' <br /> k PAY <br /> F � <br /> OUM <br /> Olr/f379�Y / P613LIC ALTH Hloly <br /> ENVIRONME <br />