Laserfiche WebLink
y APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES pp` <br /> ENVIRONMENTAL HEALTH DIVISION �FliV� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 F'11,110 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ComRllle IR TriPRual <br /> APPLICATION to HEM BY MAGE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOR}R INSTALL THE WORK DESCRIBED.TO IIB APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTERB- 115.3 ANO tllE BY <br /> OF BAN JOAOUIN COUy'1y��Y MHLW IIIIEALLTTIII SEERS ES,EN"MNMEMAL HEALtil DMBION. <br /> iP� <br /> Art <br /> JOS ADDRESMA APN CITY PARCEL BNF/APN/��7T�/y( <br /> OWNER"B NAME AUONFOR "Oom <br /> COMPACTORADORFBB aW L N VCi LIC/ Cr�Y1�PbNF. <br /> BUB COMPACTOR ADENRBB UCB PHONE <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPACEMEM WELL ❑ MONITORING WELL I ❑ OTHER <br /> 1 ❑ IHSALLATION ❑ WELL YBTEM PEPAIR ❑ CHOBSCONNECT REPAIR ❑ VAFOB EXTRACTION WELL/ J <br /> \ � 11NewRBOMr 11 D. DEPTH NMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) F-1 <br /> OU74)F ClGEOPHYSICAL\yELLI� SOIL BONN` B <br /> yyOEStnucT a XA/TYyI_ ,lll`1J�/1/1 ,INJ^/,ITI 1 /„'Y•1//IAaYT'r Y1-LYK,//1 <br /> /INTENDED USE TYPE OF Wm CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO O <br /> ❑ DOMERTICR'NVATE ❑GRAVEL PACKIBIZE TYPE OF CASINOISTttU CIA,OF WELL CASINO O <br /> ❑ MBUCMUNIOIFAL ❑DRIVEN s DEPTH OF GROW SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG Pl ❑OTHER GROUT REAL INSTALLED BY GROUT SRAM)NAME E <br /> ❑ MONITORING GROW SEAL PIMPED: 11 Y— [IN. CONCRETEPEOEBTALRYDRILLER:❑Yr [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOXIMOW FIFE 5 <br /> MOMSFD CONSTIUCNON/DISWNO METHOD: MUD ROTARY Aln AOTAIEY AMER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APRICAEgN ANO THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNfV ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY, HOME OWNER OR MENDED AGENT'S SIONATUDE CERTIFIES THE FOLLOWING:'I CERTIFY THAT RI THE PERFORMANCE OF THE WORK FOR WHICH <br /> TIOR RESMN 1 ISSUED.1 SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENFATION PAWS OF CALWORMA.- COWPACTOB'B HIRINU OR SUS COMMCTNO BIGNATURE CERTIFIER <br /> T��OILLO M. '1 CERTIFY TH TINA PERFORMANCE OF TILE MACH THIS PERMIT IS ISSUED,1 BNALL FMP.OY PERSONS INGASUBJECT TO ER AM JON'S COMPENSATION LAWS OF <br /> CAl1fOPN l APNC t M TCA ] A L A WE �ALL RFGURFD /ECTb NS AT }OSI IS -FI]]. COMPLETE DRAWING AT POWER AMA O <br /> // <br /> BI TIMI O.b LJ <br /> ROT FLAN ID,—In IM4. Ba.N IR <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OB BOUNCING TIE P O ERTY. E. LOCATION OF HOUSE SEWAGE DIOPOSAA.SYSTEM OG PIOROSEU <br /> }. OUTLINE OF INE RIORRIY.OIVNp DMENBIONB ANO NORTN CIPECTroN. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTNfO AND PEOMINIO S. LOCATION OF MMB WITHIN MdUB OF ONE NvMrSD rWT-Y P. <br /> STRUCTURES,INCLUTSM COVETED ARLAS SUCH AS PIKIOB.DRIVEWAYS,ANO WALKS. ON THE PIORRTY OR ADJOINING PROPERTY. <br /> N � <br /> 0 <br /> rc} AUG 31 �; c <br /> _ - - - ✓UisIJC HElLLTH iFf;VVCE:S <br /> 1_14VIRONMENTAI HEALTH UIVISIOI, <br /> I l DEPARTMENT USE ONLY , C <br /> nnmle.non Aaeenrwl <br /> By <br /> a.«e A.AP.INr.er Dm P.+•s BT \ ORA <br /> n,.�ncllen ImnEmbn Pv U'I <br /> fommer <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FFEINFO AMOUNT REMITTED CNECKI ASN I RECEIVED SY DATE PEMAITHIFRVICE REQUEST NUMBER INVOICE <br /> 11 ( 8711 g3 <br /> Pub Health SEW,-Enviro. 173(1197) <br />