Laserfiche WebLink
' APPLICATION FOR WELL/PUMP PERMIT <br /> I SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> v 304 EAST WEBER AVENUE, STOCKTON, CA 9520 O <br /> (209) 468-3420 J <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (COMPIGIS In <br /> stal <br /> APPLICATION IS HERE MY MADE TO THE BAN JOADHN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.TIII[APRICATION IS MAD;IN COMRIANCF WRII BAN <br /> JOAQUIN COUNTY DEWL/O�P(M)ENT TITLE.CHAFFER 5-11115.3 ANDTHE STANDARDS OF BAN"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> M <br /> JOB AODMIISMR A [f[`�Z__. �I 110 '�l)IQZS 5'1F V V eusc-lo •LfL om.C ('I71uf•{A1. PARCEL SIZE/AAM 2, <br /> OWIIFR'S NAME VN AVO011E1•e8�-OJ I�V L1t./Tl/.NI�1/YYiCO QCyD U��YPH�NF��' <br /> COMRACTOR_EVL,.11� n /'1J( QSbl1r SOC 1 (NC ADDR[S622 jarr4IDOL uc/� /�o <br /> PUB CONTRACTOR RIgNF/ 36 -3 90 <br /> ADDIEOO Uct <br /> PHONE I <br /> TYPE OF WE I/PUMP ❑ NEW WELL ❑ REI'IACEMEM WELL ❑ MONRORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM9"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I -/ <br /> ❑N—cl P.e H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL <br /> RYPE OF PVMR �j p <br /> ❑ OUT-0F-SERVICE WELL ❑ OEORIYSICAL WELL/ ((Ju BOIL BONNO Io 1 B <br /> EI DESTRUCTION: <br /> ESLVIS OF WELL CONSTRUCTION SPECIFICUS <br /> TRIAL ❑OMNBOTTOM OMdA.Of WELL EXCAVATIONTIONS u DIA.OF CONDUCTOR CASINO <br /> A <br /> ❑ DOMESTICTRIVATE ❑GRAVEL PACK/SIZE TYPEOFCASINGMTEELIPVC DA.OF WELL CASINO p <br /> 11NBl1CIMUNICRAL II❑��ONVEN DEPTH OF GROUT SEAL M'ECIFK:ATION q <br /> ❑ IRRIIJ <br /> GATION/AD IOTNER C� 'N Ns.h l OROM SFAL INSTALLED BY <br /> SROM BRAND NAME SOIL �`�E/^+4f E <br /> ❑ MONITORING / GROUT SEAL PUMPED: Ely. ❑Ne CONCRETE MOESTAL BY DRLLEH:❑Yw ❑Ne 5 <br /> AR X.BERN V Lockm CHESTER BOMMOVE FWE S <br /> moms D CONBTRgT1pR/ tum METHOD: MUD ROTARY AIR ROTARY AMER >(, CABLE OTHER <br /> - <br /> I NEEBY CERTIFY THAT I HAVE PREPARED TWO APFLLCATION AND THAT THE WORK WALL BE DONE M ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE LAWS.AM)RdEt AND <br /> MMU LATIONS OF THE SAN JOA COVNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWBM:'I CERTIFY THAT N THE PERFORMANCE OF THE WOM FOR WHICH <br /> TMS PERMIT IS ISSUED, TEMR.OY PEROONSBUB.IECTTOWMMAN-SCOMPENOAMNUWBOFCALNORMA.- COMMCTOR'GMMMDRM"ONTMCTMMNATUMCEMINEO <br /> TNF FOLLOWING: EMI THAT M 11E PEREOWIIANCE OF TNE WORK FOR NNICN TMS PERMIT M MSUEO.1 SHALL EMROY PERSONS SUBJECT TO WOIIIONAM'S COMlEN/MOON LAWS OF <br /> CALIFORNIA.- A HMUOT CO f/ WIN AOVANC[F011 ALL ROWED INSMMRG AT 1100 440401". COMPLETE RE <br /> TE pNO AT LOWER AA PROVIDED <br /> Marx TIG. <br /> ROT MN ON.le S.J.I Se.i. 'le <br /> 1. NAMES OF TWEETS OR ROADS NEAREST TO OR SOUNDIND THE FFIOPERTY. I. LOCATION OF HOUSE OEWADE DISPOSAL SYSTEM OR PROPOSED <br /> 1. OUTLINE TNE PROPERTY.OMIq DARENBgNO AND MORIN DIRECTION. EXPANSION OF SEWAGE UMPOSAL BYDTEAM. <br /> 1, DIMENSIONED OUTUI S AND LOCATION OF ALL ExMiNO AND ROMWO, I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES.INCLUDING COVERED AREAS MUCH M PATIOS,DRIVEWAYS,ANO WALMS. ON THE FROPERTY OR ADJOIMNO I MDM IY. <br /> �W y Q N <br /> 3 nLu <br /> est. <br /> 3 <br /> � <br /> DEC <br /> . T a JAQJiN t h f <br /> � prc�gGhl �.IrAL I 'v:^.b:'r 1„ 5-1 <br /> �EIn1hj <br /> v <br /> ARTMENT use ONLY <br /> AIIINeelbn AN. W By <br /> G,eul B.PneINn <br /> By D.1. n.nl Rn.P..Ren BY D.1. <br /> OrinRlbn LRp.elbn BY p.l. <br /> Een 4+APS LJP.re- c jO I(Pd e\ l I-21Ar ' F IJeAtit* acF Ef>'1� ms�c�t,�m G d -51,1)o0r7 <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> ![CODED FEE INFO AMOUNT RFMTTED C C WICAGH RECE EG BY DATE P9MITIBERVICE REQUEST NUMBER INVOICE <br /> 2 5'b <br /> -70lq /a b O <br />