SU0004755 - Laserfiche WebLink

Home Browse Search

P11, IF APPLICATION FOR WELL/PUMP PERMIT S r y li SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 9-2 304 EAST WEBER AVENUE, STOCKTON, CA 95202 9 (209) 468-3420 / NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (� I ��/ di (Complete In TripO6lbl - APTAJCATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMMANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTAPA Till STANDARDS OF BAN"AMIN COUNTY PUB C 1 EALTN ERVICFS,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSMR APNI CfTV PARCEL SIZE/ANI OWNER'S NAME AOORMB MORE 172 7-1977,1) CONTRACTOR ADpEBi / D MORE/727-,S.S'�SZ BUB CONTRACTOR ADDRESS Me MORE I TYPE OF WELUPIIMP, ❑ NEW WELL ❑ REFLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-COHNECT REPAIR ❑ VAPOR EXTRACTION WELL S J nYR OF PUMP 11 .w N—❑nN.P. OEM"NMP eET_FT. FIRST WATER LEVEL I-JA 1IV L ❑ O ❑ Son.Bolow RECEIVE(-./ B //�A Vf-0F�BER GRIYBICAL WELL •..SS..sS10N:��4L�lGa' L /ChrlLl� �E WELL EO INTENDED VBE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ WMSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCMNdASmuurA'-)VIIULOUNI' p ❑ DOMESTIORAIIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGIBTEELA'OC DIA.OF WELL CAPING UBLIDP p ❑ NBLICAAUNICHAL 1:1 DRIVER DEPTH OF GROUT BEAL SPECIFICATION 'x111 VVV��I R ❑ IMOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT BEAL PUMPED: [I Y. [j N. CONCRETE PEDEBTAL BYDNLLER:❑Y. ❑rl. S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PP S PROIOSED CONSTRUCNOPMRIL11NG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I IIAW PREPARED THIS AMMATION AND THAT THE WOR(WALL HE DONE N ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND TIEGUTATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTEIES THE FOLLOWING:•I CERTIFY THAT N THE RKORIAANCE OF TIRE WOR(FOR WHICH TMS MRALR Ie ISSUED,19I4AU NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMI INSATION LAWS OF CAUVORMA.' CONTRACTOR'S MENU OR mIBrONTRACTNG SIGNATUM CERTIFIES THE FOLLOWINO: •1 CET TNAT I NTE PRFORMANCE OF THE WOR(FOR WHICH THIS REMIT IS ISSUED,1 SMALL EMPLOY PERSONS SURIECT TO WOMMM'S COMIRaNATION LAWS OF CALIFORNIA.' TI RTIC I MUS ALL 24 HOURS IN ADVANCE FOR ALL REGWED\INB/P[CT�(1r�/ESB AST t�20S�I Atl_flZi. COMPLETE DRAWING AT LOWER AREA PIgNDEO. NJ, X TIG. y 1 I/_I(yAC/ _ D.I. ROT MN IDr.w Ie Bawl U.l. •Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PiIOPRTV. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PIOIOSED 2. OUTLINE of THE PROPERTY.GI\MIO DIMENSKINS AND NORTH DIRECTION. EXPANSION OF SEWAGE GRIMM SYSTEMS. ]_ DIMENSIONED OUTLINES ANO LOCATION OF ALL EXIST"AND PROPOSED S. LOCATION OF WELLS WITHIN RADNS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH TAA�^SS PP\AAT\IO\B,DRIVEWAYS,AND WAU(S. ON THE PROPRTY OR ADJOINIM PIIOPFRTY. EQQe �e,F 1f PAYMVMEN ) RECENT\/Ef" �; w f4A� SAN,IUAOUINCGUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV131p(y C;�,L , � EF TMDIT Vt!ONLY ARIb.Ibe Aaa.R.d Br I /` E / VVV/ D.b 151 1 U N.. -2- IZ- �i I Grww Ann.Ilw.Br ole. PI.eP In.P.U.n er D,.RnsRbn I�..n.allae ev O.I COmmmN.' ACCOUNTING ONLY: AIDo FACT M CODES FEE INFO AMOUNT KERAFTED CHECK ASH RECEIVED SY DATE PEFWOTMERVICE REQUEST NURSER INVOICE Health Sery.-Enviro. 173(1/97)