Laserfiche WebLink
t q <br /> APPLICATION FOR WELL/PUMP PER Y f O <br /> SAlm JOAQUIN COUNTY PUBLIC HEALTH SnVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplaus In THipill <br /> APPLICATION IS 14M BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMMEN/MT'TITLE,CHAPTER 9 111153 AND THE STANDARDS OFBAN LAIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J08 AODRESSIOR PNI�IJI > IV I L(x lh c-So TRE1/E} ICITV ^Y <br /> PARCEL BIZE/APN/ <br /> OWNER'S NAMECl�1 ADORES /� 1 ( PHONE, � ���]" U <br /> CONTRACTOR \ LJL ADDRESS - 1i�1�_ 1�L .UC/ �RIONE/ F-'l/-, T v1(1 <br /> woonEBB uc/ <br /> R40NE/- <br /> TYPE OF WEUJMJMP1 ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOMNO WELL/ ❑ OTHER <br /> 5 U6 /❑yRB11 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR 1:1 VAPOR EXTRACTION WELL F J <br /> AC111ev❑Rev.Ir H.P. -t- <br /> o <br /> t —O VPE OF PUMPI DEPTHMPSUM". FIRST WATER LEVEL � O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING B <br /> INTENDED U E TYPE OF W LL CONSTRUCTION SPECIFICATIONS A <br /> INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTICM190VATE ❑GRAVEL PACKISRE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PURLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIOAIMNIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPFO: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:Ely. ❑Ne S <br /> APPRG%.OF"" LOCKING CHESTER 9U%ISTOVE RPE 5 <br /> PROPOSED CONSTRLICHONIdYLIING METMO: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> - <br /> I HEREBY CERTIFY T14AT 1 HAVE PREPARED THIS APLCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> nEGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWB OF CALIFORNIA.- CONTRACTOR'8 HIRING OR BUB CONTRACTING SIGNATURE OE WHICH <br /> THE FOLLO I CERTIFY THAT IN TI PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPdBA ON UWB OF � <br /> TIFIES <br /> CANFORNI T APPJCANT MUST N FINANCE <br /> IN ADVANCE FOR ALL REGUIRED IM CTIONS AT 110 I ISSJ41f. COMPLETE DRAWING AT LOWER AREA PROVI EO. <br /> SICMd % / Q�T <br /> illls IC{ '�- /T Dns I !� <br /> PLOT PAN am—le Dow.)Sane 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PRVPEnTY. <br /> 1. OUTLINE OF THE �. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED {C} <br /> PIOPERTY,OWING DIMENSIONS AND NORTH DIRECTION' EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPGBED S. LOCATION OF MLLB WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PopESTY <br /> 1 \ <br /> � GLa.Ss <br /> r <br /> Sho S PAYMENT <br /> AUG 2 6 '1997 <br /> SAN JOAQUIN COUNTY <br /> __., � PU6lJC HEALTH SERVICES 1 <br /> --.... NTAL HEARTH OIVISIOIJ <br /> DEPARTMENT USE ONLY �]"' <br /> AvvSenl.n Avawlod BY M^./�✓ Dlmnn 1 Arr O C <br /> Ore.lrnve.Ben BY to RAnv In.Peaeen Ry_ - M'�, T <br /> Il.rVmllen In.Pmtlen BY <br /> D.1. <br /> Cn�n�nwn. <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED HEC MASH RECOVER BY DATE PfAMITISERVICE REQUEST NUMBER INVOICE <br /> D S SOL S 7 . ON�z/ <br /> Pub.Health Saw.-Enviro. 173(1/97) <br />