Laserfiche WebLink
at <br /> APPLICATION 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 /> Now-REFUNDABLE PERMIT EXPIRES 1 YEAR FR M DATE ISSUEQ <br /> IComPhIld'IB TrIPRe6ul - - . <br /> APPLICATION N HERE BY MADE 70 THE BAN JOA <br /> JOAGUIN COUNTY OUNI COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THETHIS WOHC DESCRIBED.TS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> OEVELOP``MERT TITLE..,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMMON. <br /> JOB ADORESSlOR APNE 1 3`j 7/ �' lyq ' <br /> F� ��� � E� PARCEL 612EJAPNI� - <br /> 0%%?MR'$NAME �I r"( t .�-►4t ADORES$ 1T <br /> ■� <br /> 1 d"�' PHONE,�6 3 i 33Y S <br /> CONTRACTOR A rd + t0 E r IYAh AObREBB 40~Iv-10 f wk Ler 6$6 22-L <br /> } PHONE• 116?�1�1� <br /> BUB CONTRACTOR ADOAESS Lie <br /> '# PHONE <br /> TYPE OF WELLAPLJMP. 0 NEW WELL 13 REPLACEMENT WELL 0 MOMTORINO WELL♦ 13 OTHER <br /> 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CAOSB-CONNECT pEPA1R ❑ VAPOR EXTMCTpH WELL s <br /> 0 Nary❑nw.Ir N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL_ <br /> RYPE OF PUMP) :' <br /> ll 13 OUT-OF-SERVICE WELL �❑1 4EOPHYMCAL WELL s © SOIL BORING a <br /> MDE9'TRUCTION: �� W'[115 ':� 141t ? }K -[4 tr VLS <br /> INTENDED VSE TYPE OF WELL CONiTIM710N 6PEC1yCATION& A <br /> 0 INDUSTRIAL OOPEN BOTTOM ?: DIA.OF WELL EXCAVATION _ DIA.OF CONDUCTOR CASINO D <br /> 0 OOMESTICIPHIVATE 19 GRAVEL PACK/BIMTYPE OF CASINONTEELIPVC DIA.OF VMELL CASINO O <br /> 0 PUBLICIMUMCIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ! 3 q <br /> 0 IRRIOATIONIAG 0 OTHER GROUT SEAL(INMALLED BY GROUT BRAND NAME�i]1611e C+M`K; e <br /> IN MOMrORING _/ GROUT REAL PUMPED: [ ;Y. ON. CONCRETE PEDESTAL BY OMU.M 0 Y•r ON. S <br /> APPRGX.DEPTH j Q ' p y LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CON6TRUCTIONIOIOLVNO mvrH00: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 9 <br /> I HMBY CERTIFY THAT I HAVE PREPARED TRIO APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE%"M BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULIEB ANO <br /> REOULATIONB OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERttFY THAT RN THE PEM OR64AANCf OF THE WORK FOR WHICH <br /> THIS PERMrr IS ISSUED.1$HALL NOT EMPLOY PERSONS SUBJECT TO WOWOMAN'S COMPENSATION L/1MM7f Of CALIFORNIA.• CONTRACTOR'S 11114IIG OR BUB{ONTRACTIIIG SIGNATURE CERTHIC <br /> THE FOLLOVIMM. 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WMCN THIS POWAM IB ISSUED.I SHALT.EMPLOY PERSONS SUBJECT TO WORRMAWs COMFp/fAT10N LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS M AOVAN"FOR ALL REOMED INWWTRONS AT(206144111-04". COMPLETE DRAWING AT LOWER AREA PROVIDED. p <br /> ebr,a X TIB. S� illy S�4 � tl :rS D,1. cr <br /> PLOT PLAN{Draw To Se.I.I ll• •to - <br /> 1. NAMES Of STREETS OR ROAOS NEAREST TO OR ROUNDING THE PROPERTY., A. LOCATION OF HOUSE SEWAGE OMPOBAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OMNO ONAENMP49 AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL 6YSTET:T6. <br /> 7, 0I1MEN9/ONEO OUTLINES AND LOCATION OF ALL EXWMM AND PROBED S. LOCATION OF WELLS WfTHW RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTRUCTI/RE0.INCLUDING COVERED MEAS BUCHAB PATIOS,DRIVEWAYS.ANO WALKS. ON THE PROPERTY OR AOJORBNO PpKmm TY. - <br /> ......:_ ... . ..:..............:.....,......:.................. <br /> . <br /> DEPARTMENT VSE:ONLY - /`77 //vim /J . <br /> ApOh,.M n Avow ed BY r DM• 12-1017 [ �/ <br /> Or"IrwppEllan SY O•H L P1a::p hrpeaelon BY OOa <br /> Oenniaelen fnapaeIfan By - Oat• <br /> Ce'atnenta: V 4— <br /> . <br /> ACCOUNTING ONLY' AIOf FACT `� Y <br /> PE coo" FEE INFO AMOUNT REMOTTED C !CASH RECIUVED lY DATE !@WBTNFANCE REOVE6T N mooll INVOICE41 ALE- lZI _ <br /> C .UL+ zi o/ <br /> Pub HeaM Serv.-r=nVirO.173(1/97) <br />