SITE HISTORY - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FE8 j 9 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 - MOM-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICSNp1SLS IS Ttfpkxtll AFTTICATION 19 HERE RY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AN MR INRTALL THE NONE DESCRIBED.THIS AF ICAMN 19 MADE IN COMRIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER,8-1115.3 AND THE STANOAFOS OF SAN JOAOUIN COUNTY PIBLJC HEALTH SERVICES,ENVIRONMENTAL HEALTH Dmmm. JOR AMMISIMA AFM. (p I D cLE ST 46 l�O A CITY :SA-oe-k+-an PAMEL SIMANII OWNER'9NAMETSan JoNPg'Lim COyn{tl RA)hC. 4.�OrkS E AMee 1910 EAt t' 4AzCA611 -mm,CZ4y68-3o7fI COMPACTOR laid En'v1 rbr-M6 ai MAnAACMCjnk- AMME9.701 oArk.(,r,A4-tr Dr, ml I'M HE 0-b q)5�'d2C )7 Mm CONTRA TOR 4.(r5} FtazNf D61h e Corp. AUORESS 3233 L1CP PNOHE I j(9/6)638-72J6 TYPE OF WELUPIIMP. ❑ HEW WELL ❑ REPLACEMENT WELL PGI MOMTONNO WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR /❑, CMSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J ❑N—OM. H.P. DEPTH PIMP SET FT. MET WATER LEVEL O O YNE OF PUMP ❑ OUT-OF- ICE WELL ❑ OEORrvm AL WELL/ ❑ SOR WRING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION FPECTFlCADONS A ❑ INGUSTMAL ❑OPEN EOTTOM DIA.OF WELL EXCAVATION 10-1YK % 1 NA,OF CONOUCTOR CASING NA, O Cl DOMESTICNNVATE )QOAAVEL PAMMEE TYPEOFCASSGNTFEt/1P�C PVC -InGlt DNA,OF WELL CASINO 4-IAcll 0 ❑ PUELICAAUN WAL ❑ONVEN DERIDE GROUT SEKT b/. I�L.w_._w_� SRCIPCATION R ❑ IRMOATION/AG ❑OTHER CGA GROUT SEAL INSTALLEDIN,�AEY (HIES}�67 T OROVf SMND NAME S/_R�'DNIK E XMONITORING 1 f _ ' IN N GROUT SEAL m%A EO: dye ❑Ns CONCRETE PEDESTAL BY DRILLER:❑Y- ❑N. 5 APPROX.DEPTH MIetIS TO De j V%$- (ICd all l'I' ,,�,."'rc_I-__borl('o 5 PROPOSED CONSTRLICTONgRL11NO METHOD: MVD R3TARY , 1GAM ROTARY AMER_X_CA —BLE OTHER 1 HE W CERTIFY THAT 1 HAVE PEPARED TINE AERJCATION AND THAT THE WON[WILL ME DONE M ACCOROANCE WRN SAN AAOUIN COUNTY ORDINANCES.STATE LAWS,ANO RALES AND NEOUTATIONF OF THE SAN JOAGUIN C01MFY. HOME OWNER OR MENSEO AOFHT'S SGNATIIHE CERTFES THE FOLLOWING:I CERTIFY THAT M THE PEROIMANCE OF THE WOPA FOR WINCH TWO PEWATT IS ISSUED.I SHALL NOT EMPLOY FERSONO SUBJECT TO`NORNMAN'S COMPENSATION LAWS OF CAIIMA NIA.' CONTRACTOR'S HIRING OR SUSSONTRACTNG SIGNATURE CERTIFIES THE FOLLON : 1 C17hFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT 1E ISOURM.1 SHAW EMROY PERSONS SUBJECT TO WOPPOAAN'S COMPdSARON LAWS OF CALtFORMA.- THE AMT MUST CALL fA W W IN AOVA Cl FOR ALL REQUIRED MSFICTXWW AT 12001 440Y27. MUM E DRAWING AT LOWER AREA PRONGED. Sp X 6Cola-41s+- D.R. Z1-7 ROT RAN OD,—le S..1.1 Bv.IS 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PM PERFV. 4. LOCATION OF HOUSE SEWAGE OWPOSAL SYSTEM OR FRNOSED 2. OUFLNE OF THE PROGENTY,OIVNEI gMENEMIRS ANO NORTH DITECTPUN, EXPANSION OF SEWAGE IXSMGAL SYSTEMS. J. pMENSIOHFG OUTLINES AND LOCATION OF ALL EXISTING AHO FROPOSEO C LOCATION OF WELLS WFFWN RAMPS OF ONE HUMMED FIFTY FT. 9TIMICTVRES.SNCLVOINO COVpEO MEAS SUN:H AS PATIOS,DRIVEWAYS,AMI WALX9. ON THE F"O"RTY OR AEt"INIG PROPERTY. Ply sa a�a�h. li I D9MTI ENT USE ONLY AIM1..11en Aee.sled Sr OH. �/(/�� 4r L.O. 17 G.M e,.Pe<N...Rr ��A•I/1/1 G.IS'5 _ (.'1 L 1.PI.YNMIIen Er 0.'. I ml o..mtlla.Irw.�.fen eY lIN NL AIOI PAC. P!CODES FEE TNFG AMOUNT REMITTED CHEC"MASH RFCERMI BY GATE IEEAT EANCE REOUTST NUMBER INVOICE 3So1 �! aa bzeEff �S�