Laserfiche WebLink
soPLICATION FOR WELUPUMP PERM{' <br /> SAI. .QUIN COUNTY PUBLIC HEALTH SEP. :S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triprieatel <br /> APPLICATION 18 NEM BY MADE TO THE SAL!JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELO•1PMENT„jrTM CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DM(SSIObL( <br /> JOB AnnnESS/OR APHI ,{/.0'Z•D ARK. CRY L' ` I��.I._`f PARCEL SIZE/AP..J t �J ) <br /> amawn NAME /V I I ' ADDRESS PHONE l <br /> CONTRACTOR ADDRESS /CST•"d"/ PHONE I �7/�'''J 7 /62 <br /> 1 <br /> 5c ADDRESS—ADDRESS / PHONE <br /> SUR CONTRACTOR <br /> Iciam <br /> TYPE OF WELUPUMP: 11NEW WELL C1REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ Cn0SS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ <br /> ❑New Q P. -k M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> RYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL/ SOIL BORIIJG S <br /> ❑DERTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMF.STIC/PRIVATE ❑ORA L PACK/SIZE TYPE OF CASING/STEEL/PVC OLA.OF WELL CASINO 0 <br /> ❑ PVnLIC/MUNICtPAL RIVEN DEPTH OF GROUT SEAL SPECIFICATIONR <br /> C61IRIIfpAT10NIAG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME f <br /> `^' NITORINO GROUT SEAL PUMPED: C1Y— ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Y- ❑No S <br /> APPROX.OEPTH LOCKING CHESTER BOX/STOVE PIPE •s <br /> PROPOSEn CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTH <br /> I HE'IFRY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> nF.GUt ATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> TI/IB PFnMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE rnL1.OWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALITOnNIA.- T CANT MUST A LIRA IN ADVANCE FOR ALL REQUIRED INr/SPEC TIONS AT 120/1 4"t 3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 81enM X Title ` Det. / Z/ <br /> PLOT PIAN(Drew to Seelel Seele 'to <br /> 1. NAMFS OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE ABPOBAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE o1SPVS D SOF ON <br /> J. DIMFN910NED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTTTtN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ST n11CTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ......i... .... ... .. .. : ..._. , .. <br /> I <br /> w. <br /> :. <br /> h <br /> ;!4S DEPARTMENT USE ONLY <br /> 'at O1/ <br /> .µ-... sY—licna CitMA O I <br /> Dete Arr <br /> .♦ Dete ad O Pune Inepeetlen BY Debe <br /> i•y"�r•,'' O..Mutlew M"N�eellen RY <br /> I Dete <br /> • Cww..erwet <br /> ACCOUNTING ON,, AID/ <br /> FACS <br /> PE CDO/e FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED SY DATE PETUMTISERVICE REQUEST NUMBER INVOICE <br /> -2—-Z— 1I <br /> Pub,Health SerY,-cnYtro. 173(1/97) <br />