Laserfiche WebLink
See <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OZJ.6?J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 476 N.SAN JOAQUIN ST.,STOCKTON.CA 96201388 <br /> (209)4683420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> HiesPMnm Y MYRON) <br /> AppLication is here by rode to the Sen Joaquin County for a permit to construct end/or inst Ll the work descri6W. This application is <br /> Riede in cespiiance with San Joeglin Canty Development TitLe, Chapter 9-1115.3 end the Standards of San jmWin Canty Plbtic Health <br /> Services, Emiromantal Heal(thh/Divi/sioon. ///'��// <br /> Job Address/or APNNOb l� C � Pal City z,,/, Parcel Si xe/APXY <br /> Owner'sXroe �r e - ARetire. Ph.# <br /> `/ <br /> Contractor, —Q//( ��C;s Address LIcp3laS!2 Phan$S 3 <br /> SW Contractor Address Lich Phone S <br /> TYPE OF HELL/PW: D NEW WELL 0 REPLACEMENT WELL O MONITORING WELL B [1 OTHER <br /> 0DESTRUCTION [I WT-OF-SERVICE WELL 0 GEOPHYSICAL WELL N 1) SOIL BORING <br /> [1 INSTALLATION 11 WELL SYSTEM REPAIR 11 CROSS-COMMECT REPAIR 0 VAPOR EXTRACTION WELL N_ <br /> II Mw XxOpeir N.P. _ DEPTH PUN SET [ j�iT. FIRST WATER LEVEL_ <br /> (TYPE OF PMP) <br /> INTENDED USE TYPE OF WEII CONSTRUCYIDM SPECIFICATIONS <br /> 0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATIONDIA. OF CONDUCTOR USING <br /> `F DMESTIC/PRIVATE 0 GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL USING <br /> [1 PUBLIC/MN ICIPAL 0 DRIVEN DEPTH Of GROUT SEAL SPECIFICATION <br /> (1 IRRIUTION/AG D OTHER ERMT SEAL INSTALLED BY MIKE BRAIN NAME <br /> D MONITORING / GROIT SEAL PUMPED: [1 Yea 11 No CONCRETE PEDESTAL BY DRILLER: 0 TN 0 NO <br /> /-Y <br /> APPROX.DEPTH ` S LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIOMDRILLING METNDO: RD ROTARY_AIR ROTARY_AUGER_CASLE_OTHER_ <br /> 6 <br /> I M1ereFry certify that 1 M1eva pteparad tMc application and that the work Wil be date in¢cordsnce with San Join Canty OtdfrtMMes, a <br /> State L. esd RuLes aM ReguLetian of the San Jomouin Canty. Marc inner or license l agent's si,netwe certifies the following: •I <br /> certify that in the pe,for .of the work for which this permit is iasued, 1 sheik not se,t,OR,.suOj.,,to WORRILL COMPENSATION 6 <br /> Law of California,- Contractor's hiring or sub-contracting signature certifies the following: a 1 certify that in the per-f..6 <br /> of the work for Which this parelt I. issued, 1 chalk mploy Persons su6jact t0 WMXMAM'S COMPENSATION Laws of Cd(fornia.• THE APPOCANT <br /> MUST CALL 24 HOURS M ADVANCE FON ALL REQUIRED INSPECTIONS AT(20914N-31U3. CmgLete drawing at lover area Pr LVidel. <br /> �I <br /> Date <br /> SigneTitle �>?OT� <br /> d <br /> PLOT PIAN (Draw to Sole1 Scale__• to_ <br /> 1. Messes of street$or roads roar... to or ho"iro the property. b. Location of horse Sewage disposaL $y.tom or <br /> 2. Milne of the property, I,IM dimensions end North direction. proposed enperuion of sewage disposaL systems. <br /> 3. Dimensioned aotl Enes end location of &L1 existing Md proposed 5. tion ..LLSwithin <br /> property. <br /> iu, of 150 ft . on <br /> structures, including covered areas such a$ patios, driveways, the property or ng p <br /> and walks. <br /> ---------------- <br /> -1—ft------------- <br /> 0 2 1 <br /> P LIC EnL X <br /> MacN <br /> DEPARTMENT <br /> /ARTYEMT USE ONLY �. .Jl_�L <br /> Appti—Liao Accepted BY <br /> Grout Inspection By Date Pulp Inspection Ry Data <br /> Destructior Inspection ly Data cw ton: <br /> ACCOUNTING ONLY: AI DN fA[N <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED By DATE PENMOISEUME REQUEST NUMBER INVOICE <br /> 5 11 7 � bMd96 <br />