Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT OST ©Cf <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �U <br /> ENVIRONMENTAL HEALTH DIVISION WELL / �i to <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 ••7iFF <br /> (209)468-3420 <br /> �✓LS�// 7�� < IION-AMOVAILE PERMIT EAIIRES I YEAR F110M DATE ISSUED <br /> L G (Gsylets III TrbIEHd <br /> APPLICATION n IMRF by MADE TO THE SAN JOAOVN COUNrY FOR A PERMIT TO CGRITTTRUCT ANONR INSTALL THE WORT DISCAIRFD.THIS APPLICATION M MADE N COPARLIANCE WRIT SAN <br /> JOAOUN COUNTY OEVROPMENT TRIS CHAPTER 9-1116.9 AND HE STANDARDS AWN COVCNTY�RI MJC N 7H SERVICES.EMVIADNMENTAL HEALTH DM"ION. <br /> JOS ADOREW,oR AP/IF �j /J s ( _/p CITU J CZ- C�—� P [l SI <br /> OWNER'S NAME A v Vl.CT VVYL-� - ADORESS N f A1DIA <br /> cOMRACTOR� L�--� ADORE 1/I I1Cl oya -No-� <br /> NIS CONTRACTOR ADDRESS Uc. PHONE/ <br /> TYPE Of WELl1R11� ❑I:EW WELL ❑REPLACEMENT WRL ❑IAOMIToRNG WELL E1❑y OTHER MO ' <br /> ❑NATMLATON ElEA <br /> Wt SYSTEM REPAIR ❑cRaso CONN,EcTT"PM1_J R VAPOR EXTCTN WELL <br /> W—❑P—i, H.►, US""MAP SFT. •f FT. FIRPT WATFRtFVTL/nr ' O <br /> M YPE oP pumn JEP �6'�� <br /> OVT-0P-SERVICE WELL Q OEOPHyWM,WELL J ❑ No,Non.IG R <br /> ❑OESTIEICTION: <br /> .TENDED ust TY►s OP Co" <br /> TIONS (FICA ONs A <br /> ❑wmsInAL ❑OP[N bo"a" DIA.1)F WELL EXCAVATION DIA.Or CONDUCTOR CASINO O <br /> DOAENTR:XPIVAtt ❑GRAVEL P—KiwE TYPE OF CAINOMT"t Io C DIA.OF—L CA— D <br /> ❑PU8L CAAVHICIPILL ❑DNVEN DEPTH OF orom SEAL SP.CSICATION A <br /> SwUOATONIAO ❑UTHER ORDUT SEAL IMiALtED FY WOUT NRAM NAME E <br /> ❑MDNTORNO GROUT SEAL nIMMD:❑Yw ON. CONCRETE PfUlSTAL SY DRNLER:❑Y- ❑N. S <br /> APPROX.DEPTH LOCKING CES:STER SOIOfTOVE PR <br /> 6 <br /> PROPOSED COMSTIIKTORA)RRIINO METHOD;MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HRSY CERTIFY THAT 1 HAVE PREPARED TORN APrLKATIOM AAV THAT THE WOM WILL bE DONE N ACCORDANCE WITH SAN JOAOl1R1 COUNTY OIONANCES,EFATE LAWS.AND RULES AND <br /> RG111 ATOMS OF THE SAN JOAUUM COUNTY.HOME OWNER OR;ICHMWO AGENT'S SIGNATURE CERTIFIES THE FOLLOVAIO:•1 CERTIFY THAT IN THE►FTEOR LANCE OP THE%%low"RW ICH <br /> MS relaoT IS IUIU .1 MALLNOT EMPLOY PERSON■JUS RCT TO WORSU,IAM'S COMPENSATION LAWS OF CAIITOAMIA.-CONTRACTOR'S HIRING OR SUBCONTMCTINO SIONATLHE CERTIFIES <br /> THE FORLOYRMG; I ClRTIFY tNAi N TT I RM IC[OF THE VlV nR FOR VAOCII THIS PUMrT IS ISSUED.I SHAH EuKoy PER"ONs SUs.ACT TO RORRGTAN•S EOM AROX LAWS Of <br /> CAL1F011M A►UCANT MINT lD IM CT <br /> FOA A4 REQUIRED IIRSPSC 110Ms AT UMI Ar.l.7S.L'OMILETE OMWMG AT L.OVFl11 AREA PIIDN DED <br /> 911.4 x 1111. DN. <br /> ROT WR . <br /> PID1.7"6 <br /> W 't. <br /> 1.NARES Or STRFTs OR RDAV E NEAREST TO OR SOUROFJO TETE RTOMPITY. S.LOCATION OP HOUSE SFWAOE OI.POsAL SYSTEM OR PROPDSED <br /> Z.OUTLINE OP THE P PERTY,Or~b"NSIONS AND NORTH DIRECTO". EXPANSION OF SEWAGE DtWOSAL.SYSTEM". <br /> ].OIMENNOMED OUTLNRS AND LOCATION OF ALL EXIST"AND PwDPOSFO N. LOCATION OF VYRLS VVITIM RAMS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES,NCLU]NG COVETED AREAS SUCH AN PATO;DNVFWAyS,AND WAIx N. ON TREE PROPERTY OR ADJONIMO PIIOFW". <br /> .... T.. ...t ' <br /> i <br /> j. <br /> , <br /> t <br /> I..........i... <br /> I R <br /> �g98 <br /> SAO h-IpN{ <br /> T <br /> G ylf. yY I I <br /> € E. <br /> i <br /> ; <br /> ��' (1�J/ l.f .l.�—^ OS►M1M[NT VSE OwIrY_A,PF370 <br /> AnN..R.n M.wl.d Sy <br /> a,.,,I Ir.....R.n eT D.,. ►.,,.v 1mP.a1.n"T _D.R:f-'�i_�.L Cf� <br /> I7AI,ls,l.n I,vP..M.n By O.t. <br /> ACCOUNTING ONLY: AO/ FACT <br /> R COOED FEE INFO AMOUNT ROWTTTD CiTEC ASN RECEIVED sy DATE ►BLb11TH9W1 OEVOI[:< <br /> ' oSU SZJ 0 r9s6 s <br /> Pub.Health SeIv -Erwim.173(1197) <br />