Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> T r SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N SAN JOAOUIN ST.STOCKTON.CA 95201 388 <br /> ' {209)4613420 <br /> . <br /> NOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Mompkls tB TIIpIkazo) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLFL CHAPTER 9 Ill 5 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E"RONMENTAL HEALTH DMSION <br /> JOB ADDRESMMR APHI //r 1-1-11 /Y OW6 6✓RI/ .�CPTY SrL f,(�fy71P� PARCEL&'LFIAPN/ <br /> I I <br /> OVMFRB NAME_L�NCIlA'f.1/__r.�c✓JTlCF:r CL'7rAlP2,T ADORERS P (/ BUA SPA I11A)A�A/FFAAW PHONE IF -106 C <br /> CONTRACTOR _C.P,,,FtGE 1 ADDRESS.PW 4-0-d LIC# %G?7.3 PHONEI!'`J/L)651 IfLG <br /> SUBCONTRACTOR T,'/al!l�EC�fid✓CAriN✓�K� ADDRESS ITl1 C/INTA/L�II�;�/i.f6!!/LIC# f�;/ PHONE/E� Jt`6%.Z/f/ <br /> TYPE OF yVELLMUM�, ❑NEW WELL ❑REPLACEMENT WELL ❑MONITOUNG WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL smEM REPMR ❑CROBBCONNECT REPAIR 17 VAPOR WRACTRON WELL# J <br /> 13 N—Q%P.& A H P ' � DEPTH PIMP SET FT FIRST WATER LEVEL O <br /> EPYPE OF PUMPI d L <br /> 0 WELL Q OEDRYSAEL,)L R so RING • <br /> J -STRUCTION <br /> YiOA^.-1`0--�-lftA--/C <br /> I I = <br /> INTENDED USE TYPF,OF WELL CONS TRUCTI.*414CIrI0ATIONs •���������������—�����—���—��—�— A <br /> ❑I�I INDUSTRIAL ❑OPEN BOTTOM I]V1 OF WFELt EACAVATION ORA,OF CONDUCTOR CASINO O <br /> LJ bOMEDTICfPTVATE ❑GRAVEL PACKMZE TYPE OF CASIHdrfTFEpPyC INA OF WELL CASINO A O <br /> ❑PUBUCIMUMCIPAL ,❑�DIVVEN DEPFH OF GROUT SEALS SPECIFICATION R <br /> ❑IARIOATgWAG Q OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PIMPED ❑Y-,❑N. CONCRETE PEDESTAL BY DPILLFR.❑Yw ON. S <br /> APPROX.DEPTH LOCKIND CHESTER BOXNTOVE PIPE S <br /> PROPOSEDCONSTRUCTIONIDPoLUNG METHOD MUDRDTARY AIRMTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPICAYION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULED AND <br /> REGULATIONS of THE SAN JOAMINCOUNTY HOME OWNEA OR LICENsEO AGENT s stamATURE CERTIFIES THE FOLLOWINO 'P CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PAMIT Is IssULD I SHALL NOT EMPAY PEASONS SUBJECT TO WORKMAN S COMPEHsmtoN LAWS OF CALIFORNIA CONTRACTOR B HIRING OR SURCONTAACTMO SIGNATURE CERTIFIES <br /> THE FOLLOWING 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF <br /> CALIFOANIA. THE AP/PJCANT MUST CALL 74 ROU U IN ADVANCE PON ALL REOUIRM INU41CMCNA AT WGSI../ 23 COMPETE DRAWING AT LOWER AREA PROVIDED <br /> BlFnwl x�/Ls.l A_)....�,t _._l_1--7_ LY'_AC.vCKI.. __ _ THh .�.>I/ (rr,.(C( 171- D.. <br /> ROT PLAN(CW—I.Swl.)S" <br /> T NAMES OF STREETS OA ROADS NEAREST TO OR BOUNDWO THE PwrERTY A LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1 OUTUNE OF THE PROPERTY GMNG DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE OISPOSAL SYSTEMS A <br /> 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED s LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> sTRVMF.EB INCLUDING COVERED AREAS SUCH AD PATIOS DW VEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> V <br /> 11rLa IF h ry a'w-LI � z a <br /> I <br /> y r 75 o L <br /> I �� <br /> 4 ,. ,. •• � �� 1-T!rdll+Df Li <br /> fa <br /> �I�]{�'�/� DEPARTMENT USE ONLY <br /> GLIA AMP.NI.11 BY,,,,_..-.._..__ ` O.e. P.GP Ypstlm DT DNw k <br /> y@ y xF <br /> f 4 DrUueWn Ir+P.glien pY � ' P � D.I. <br /> ��"- C.nxn.m. ! ��, , I � 1-y✓' �--- -1 w c, <br /> ACCOUNTING ONLY AID# FAC. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKPMAiH RECOVED BY OATS PERMITIAERVICE KEOUFJT NUMBER INVOICE <br /> u q 1q 21 Ti7 115 1 <br />