Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES } <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX SK 304 EAST WEBER AVENUE,STOCKTON.CA SMI-388 <br /> f209j 408-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (rAmpl{I{In TTIpRal{) <br /> APKL ATF N IS HERE BY MADE TO THE SAH JOAOUN+COUNTY FOR A PERMIT 70 CONRTRUCT ANORMN INSTALL THE WORK DESCRIBED.THIS APFUCATON W MME N COMPL,ANCF W"It SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER <br /> /j0-1115,/1 AND THE STANDARDS OF SAN JOAQUIN COUNTYPUBUC HEALTH SERVICES,FNVOIONMENTAL HEALTH bIvUUWI. <br /> JOB MDREam-t AMI_ ` Lr(n 4• CX_.A /14:�1�-r�.n O <br /> C=T/ �// yl � /], �`•�j]� PARCEL MZUAPN/ <br /> OWNER'S NAME L V Z� (.G �_ i 3 <br /> COMRACTOR A.13. ? PUONE�``' <br /> � <br /> "CONTRACTOR ADDHE98 LIC! P1101E <br /> F MP: 11 NEW <br /> NEW WELL J❑---TL REREPLACEMENT WELL EJ❑T---�I MH ONOpt..WELL 1 ❑OTHER <br /> IJ NSTA�TLLATION U WELL SYSTEM REPAIR Ll CROSS-CONNECT RRA <br /> EPAIR ❑VAPOR FXTCTION WELL F j pig <br /> ❑N..0 Flaps H.P.�'l�.e(� DEPTH PUMP SET R. FIRST WATER LEvfL p�1 <br /> IT EOF PRM% <br /> C-� <br /> ❑OUT-0FFENVICE WFI I. ❑OEO%ry61CAL WELL F ❑ BOS ROMW g <br /> 0 DFBFRUCTION: <br /> Nt DRDED USE TYPE O ELL CONSTRA <br /> ❑D INOUBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.Of CONDUCTOR CASINO O <br /> IJ PVMLWGQMtSCIPEVVATE ❑GRAVR PAGilUTZ,7TYr,r OF CASINOIATF,F.UT'VC DIA.OF WELL CASINO D <br /> ❑PVRUCJMUMCIPAL ❑DAVEN DEPTH OF GROUT SEAL 6KCIFMATION S <br /> ❑SIRlaATO WAO ❑OTHER GROUT SEAL INSTALLED BY SROUT BRAND NAME Cl.. E <br /> f3 MONITORING OROUT SEM.PUMPfb:❑ TE Yu ❑N. CONCREPEDESTAL BY OWLLER:❑Y« ❑ d <br /> APMOX.DMH LOCKO G CHESTER 9OXJSTow PFEa <br /> PROPOSED CONS'MUCTIDNpryWNG METHOD; MUD RDTARY_ AIR ADTA1Y AUGER CABLE OTHETL <br /> 1 HEREBY CERTIFY THAT I 1/AVE PREPAWO THIS APPLICATION AND INAT THE WORK WILL EN:GENE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES,STATE LAWS,AND FIMS AND <br /> RFOULATIONS OF THE SAN JOAQUIN COUNTY.{RMF CW Ull OR LICENSED AOENT'S MONAMPIE CERTIFIES THE FOLLO'MNGt'1 CEPITIFY THAT M THE PERFORMANCE OF TIE WON(Taq WRSCH <br /> THIS PFRAOT IO HLOMD,19NML NOT EMPLOY PFRAONS SUBJECT TO WORKMAN'S COMPSMATION LAWS DF CALIFOWIA'CONTRACTOR'S ENRINO OR SUBCONTRACTING SOHATURE CFMEIE9 <br /> THE FOLLOWING: -1 CEMIFY THAT N THE PERFORMANCE OF THE VARY FOR WHICH TM{"RIOT IS ISSUED,I WALL EMPLOY PERSONS SUBJECT TO WOIDOAAN'{COMPENSATON LAWSOF <br /> CAUMUS <br /> POINIA.• APAICANT T CALL N MU ng IN AOVANC{FOR ALL REGU UD INSPECTIONS AT rjW ASSJMYI COMitTF DRAWING AT LOWER AREA UV10Eb. <br /> PLOTP""IN—SewW Saw ��ir..�ro�_ <br /> 1.NAMES OF 9TMFTS OR WAGS NEAREST TO Oq 8011.01-0 THE PJYIPEIRY. —� ♦.LOCATION OF HOUSE SEWAGE nUm"AL SYSTEM OR pPo V SED <br /> 2.OUTLINE OF THE PROPFRTY,GIVING DIMENeIONB AND NORTH DnXCTION. EXPANOTON OP MWAOF DISPOSAL SYSTEMS. <br /> �.DINIFIMONEO OUTU.E{AND LOCATION OF ALL EMSTWp AND P110POSEO S, LOCATION OF WTLLB WITHIN RADIUS OF ONE HVNbFWV FIFTY R. <br /> SHIUCTUgEB•INCLVOWO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAtXS. ON THE PTgPEREY OA AJJDNNG FRRDPETITY. <br /> f✓may... ,f <br /> . I <br /> C4_f/ <br /> v , <br /> .. yE 1 N �y�ry'L <br /> .ri <br /> :. :. J OAiitjf,,e,,aA;I <br /> /� <br /> .. ....a...1, ..... l':LY <br /> EP TxtL.H ALTF�IJV! <br /> 9EJ'ARTItt@NT USE ONLY <br /> APP+Iutbn <br /> A—-1 BY <br /> DUAA.u � <br /> dpM MnpeaSen 9y Or Pure I_-0_BY <br /> Oerl„rlbn PnPenlen BY„ Dwp <br /> CanndN� <br /> ACCOUNTING ONLY: AID/ FAC! <br /> PE COpF.1 FIX INTO AMOUNT RENATT[D �CNE�CIpU�ASN gL'CEIVED SY DAFE PFRMNT/SERVICE AF.UEST NUMBER N/^Vp CE p p <br /> � as <br /> Pub.Health Serv.`Envio.173(3,98) <br />