Laserfiche WebLink
OPLICATION FOR WELL/PUMP PERMI10 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> 11101111-AEFUBDABLE PERMIT EXPIRES 1 YEAR FRAM DATE ISS ED <br /> APPLICATION IS HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONE(ComPRUCTlete hn Trr/Ogestol LL THE WOW pESCRIBED,THIS A �•IS 3 9 <br /> JOAQUIN COUNTY DEVELOPMENTT 1TITMI CHAFIFAEp&111 S.3 ANO THE <br /> STANDARDS OF SAN T JOAQUIN COUNTY R18UC HEALTH SERVICER, IS AFUNICATICH HEALTH IN COMPLIANCE <br /> WTTIE SAN <br /> JOB AOORESSroq A�R•II �l(�1�,Ci+y�G(„�� ' .L /� <br /> CITY. <br /> m�-�-�C�I —1U _Q p <br /> OWNER'e NAME S'—fe, 1�-6LG_y.,_Slsa./yyh ti 1 H' POMMEL Fk���-, O- 0 <br /> CONTRACTOR <br /> �2eGG 021LL)A & o zpz <br /> +Lo NS�Lf/}Iv-T AMMON 950 kbUe S+ MA(,1'Ti�tj e,-Uci GSb ejaIHt -S Yoo <br /> ����N ADDRESS_`lI2D DLL C+t• rF+'rRJCS P(Lg1 A�m'LnEF ZL•ZLOD <br /> 5 <br /> TYPE OF WELLIPVMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> ❑ CRO98CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑New❑Repelr N.P. J <br /> (TYPE Of PLIMPI DEPTH PUMP SET__Fi, FIRST WATER IEVEL <br /> ❑DESTRUCTION <br /> O <br /> 13OVT-oF-SERVICE WELL ❑ GEOPHYSICAL WELL I N <br /> X SOIL BORING S <br /> : .jam - <br /> t > <br /> INTENOfO USE TYPE OF WELL CONSTRUCTION IPECiFICATIONI <br /> 1 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> N ❑ DOMESTICIRgVATE 13 GRAVEL PACK/BRE CIA.OF CELL CASORCASINO <br /> TYPE OF CASING/BTEEI/PVC GIA.OF WELL CASING <br /> ❑ PVBUCRRVNICiPAL El DRIVEN O <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER R <br /> ❑ <br /> MONITORING GROW <br /> SEAL INSTALLED BY GROUT BRAND NAME E <br /> GROUT SEAL PUMPEO: ❑Y. ❑Na CONCRETE PEDESTAL BY pRILLEiO❑Yw ON. S <br /> APPROX.DEPTH <br /> LOCKING CHESTER BOXMOVE"I <br /> W10POIED CONITAUCTONAHBWNG METHOD: MLAO PKIJ <br /> AIfl ROTARY AUGER CARIE <br /> OTHER <br /> I CERTIFY THAT I HAVE RIEPAR U THIS APWJCATION AND THAT THE WOW(WILL BE GONE IN ACCORDANCE WITH BAN JOADUIN COUNTY ORDINANCEH.STATE LAWS,ANO RULER AND <br /> REGULATIONSHISPERIT I OF THE SAN MAOOIT COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CDTTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERTORMANCE E THE WORK FOR WHICH <br /> THIS RPMR IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP SATDN LAWS OF CALIFORNIA.- CONTROCTOWO HIPoNO OR BUBLONTRACTINO OMNATURE fI <br /> THE FOLLOWING: •1 CERTIFI MIT THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PER18 ISSUED,I SHALL EMCER"W <br /> KOY PERSONS SUBJECT TO WORKMAN'S COMPENAATOM U OF <br /> CALIFORNIA.' THE APPUCANT U T CALL 24 HOUNG IN ADVANCE PER ALL REQUIRED INSPEC DO�NO AT P041 484423. COMPLETE GROWING AT LOWER AREA PRO DED. <br /> TIO. .d'L r�C4t a y_ <br /> D.I. <br /> OT FUN IOr.Ie Sa.1.1 Be.l. •b <br /> I. NAMES OF STREETS OR O-Y,a NEAREST TO OR BOUIjDIMG THE PROPERTY, <br /> 2. OUTLINE Of THE RIOPFRTY,GIVING ORAEN61ONS AMISS NORTH DIRECTION. 4. LOCATION OF HOUSE E DISPOSAL <br /> A SYSTEMS.SYSTEM on FPDrO6ED <br /> O. DIMENOMMED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DIIPOBAL gYBTEMg. <br /> STRUCTURES,INCLUDING COVERED APEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. I. LOCATION OF WELLS WITHIN RADIUS OF ONE HVNORED FIFTY FT. <br /> ON THE PROPERTY OR AI PROPERTY. <br /> CGS IL�•d.. 'f ,... <br /> S a �.. DCS . .. <br /> �j4-x,..x•.� <br /> ... <br /> d, . <br /> . .b C : ; <br /> ^ / D6ET Y15 ONLY <br /> Apptl <br /> bbn Aaawld By /l - f /�/ 0j'L- <br /> L/I O <br /> DN. Mee <br /> Grpul lr,epevrlen BY <br /> D.la Purls San Sy <br /> DeHrmrbn Ir.menlen BY Deb <br /> Dele <br /> Cemmeme: <br /> ACCOUNTING ONLY: AIDI FACT <br /> PE CODES FEE INFO AMOUNT RVATTSO CHECXI/CAIN RECEIVED By DATE PEPMITUFRVICE gEOU i NUMBER INVOICE ) <br /> 00 l 6 3 z r„� <br /> Pub.HeaRh Sarv.-Enviro,173(1/87) <br />