Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201-388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICRIIplete In Tripkate) <br /> APPLICATION IS HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 <br /> 5,3 AND THE STANDARDS OF BAN JOAOUIN COUNTYPUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRE881OR APN! CITY//40A I PARCEL 812FIA'HT �p <br /> OWNER'S NAME t1 C2 /� / NC! O _ Anal CNE767--1 <br /> CONTRACTOADDRESS P'01 (!d <br /> n <br /> ! ( UC'tj94.3?3FHDNE.3&q-277q <br /> BUR CONTRACTOR ADDRESS LICS PHONE <br /> TYPE OF WFLUPUMP. ANEW WFLL )S(REPIACEMENT WELL ❑MONITORING WELL S ❑OTHER <br /> E❑INSTALLATION ❑WELL SY M REPAIR ❑CPOSS-CONNECT REPAIR ❑VAPOR EXTRACTION <br /> WELL f <br /> _ }e!Nµ❑R•oa* H.P. DEPTH PUMP eET�Fi. FIRST WATER LEVEL <br /> RYPE OF PUOMPI <br /> ❑OUT-OF-SERVICE WIIL (❑OLEO}-PHYSICAL WELL♦ ❑ SOIL SONNO - <br /> �ESTRUCTON: �� (ilJ / 1-IJP J M l,n!V Dvv, ) r� O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A— <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION f[7� DIA.OF CONDUCTOR CASINO <br /> ❑DOMESTTCIPRVATE 0-RAVEL PACY4812E1 TYPE OF CASINGlSTEELNVC P. V DtA.OF WELL CASINO <br /> ❑r IV BLIClMLUNICIPAL ❑DRIVEN DEPTH Of, 1!T SIfr�PAF�lSFECIFICATON 5 K RIF r^ <br /> IQ.IRNOATION/AO ❑0T11ER GROUT 6 <br /> FUM <br /> 8- ` GROUT BRAF140 NAME� M %G <br /> ///❑MONROPINO p�'Y GROUTS PUM A P Ir E�EJp£DESTAL BY DRILLER:�'� ❑No S <br /> APPROX.bSTTN (J Cl ! ITIM <br /> r� STFR SOX{/�S,T�OVE F41 L 11• `l S <br /> PROPOSED C0111TIIIA:TIONID/1rLUN0 METHOb: MLX)ROTARY_AIR ROT 1 IL}mlVAbAW6AB).F,Ay._ OTHER <br /> work hA) n 6^--1U WIT�t — <br /> I INEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WVRC WILL BE DONE I IWACCOTW O�.FI rL4A �C}U Y OROINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOEM'S',jLp,('NAT�y{FH TIHECAJO' 1NWNV;_• � 7TfI, O OR CUBLOHTRACTING HBIGNATURE CERTIFIES <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMKMSATIO �Idd F:1'1' .•p/I7p� <br /> THE FOLLOWING: I CERTIFY THAT IN THE PEPIPORMANCE OF THE WORN FOR VJMCH THI8 PERMIT 181SSUE0,I BNALL EMPLOY/PERSON 6��UBJELT TO WOP"AN'S COMPENSATION LAWS OF <br /> CALIFORNIA. <br /> _'/LT(FJ�,Ey APPLIICCAATT MUl CA7`�2/. HOVR-S•IN^"V�ANCE FOR ALL REOVIP D INSPSCTI�ON/S//•1TT f"01 44SS422.COMPLETE DMMANO AT LOWER AREA PHOODED. <br /> � !V C/VWKLlWr� �! ! �l-�l D.1• <br /> PLOT PLAN ID—Ie S-1.1 8w'. le <br /> 1.NAMES OF 9TREET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> J.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PIOPOSED S. LOCATION OF WELLS WITHIN KAONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> P�ulld,ti yp�e ¢� <br /> .. <br /> ,rte <br /> G <br /> d >( <br /> P _ <br /> 0 AYF,fl <br /> Lv l sad ,F,OU N couN ry <br /> bEPAPRMFNT USE ONLY ( LNVIHONMEIN'1 AL HEALTH DIVISION <br /> A1010-A—pt.!By �i.��—� _ Oals �'LQ" A,y Zy <br /> a'..Impe<II-BY.._.r._____- O.te P—P 1--tlan by Det. <br /> De•huctbn Inp.etlon By <br /> Da, <br /> comm«, <br /> ACL GLINTING ONLY: MIDI FACT 7 <br /> O LO'7- <br /> EC <br /> PE CODES FEE INFO AMO VNT REMITTED !CASH RECOEO VBY DATE PERMIT/SERVICE REQUEST NUMB / NVOICE <br /> q3� �a <br /> 4 3Afn� b <br />