Laserfiche WebLink
r APPLICATION FOR WELIJPUMP PERFP' ' <br /> SA iOAQUIN COUNTY PUBLIC jftTH SE. (ICES <br /> ENVIRONMENTAL HEALAWISION r"T <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 } <br /> (209)468,3420 1 <br /> a <br /> NON REFUNDARLE PERMIT EXPIRES 1 YEAR FROM RATE ISSDED ,r <br /> MompAt@ In Ttlp&.t@l <br /> APPLICATION Is t1EnE by MACE TO THE SAN JOAGUM COUNTY FOR A PERMIT To CONST11=1 AND/on INSTALL THE WORK DESC NICO 7103 APPLICATION IS MADE M COMPLIANCE W PII SAN <br /> JOAO"N COUNTY DEVELOPMENT TITLE,CHAPTER B 1115 3 AND TILE STANDARDS OF SAN JOAOIIIN COUNTY <br /> F1TeL1C NEALTII TERYICES ENVIRONMEMAL HEALTH OMMON <br /> .EDB ADORESSbR AP- 2 / /,S/ !I CITY IA-1 1 r r <br /> PARCEL St;FJAPNi <br /> OWNERS NAME !i r� <br /> /,! !/ l ! /�' AbDllEeaJ } <br /> CO17TRAC TOM1 PHONE P <br /> AODRESB T 1 Y-' r M UCO <br /> OM CONTRACTOR '-J!05'l <br /> } PHONE F ' . r ' <br /> ADDRESS / ,( <br /> OP WEL MP ❑NEW WELL 0Ri4/ICEMEN WEIJ, ml HIT (N WELL f /,llr ❑OT <br /> HEIL— <br /> ❑INSTALIATION [I WELL SyfttM FWpAIR LJ yMTS{ONNECT HEPAm ❑VAPOR EXTRACTIONP <br /> I--I J <br /> N--Lf Rbdr N P bEPfH NMP SET FT FIRST WATER LEVEL <br /> A YPE OF IVI.1% • -^ <br /> ❑OUT OF-EEnmE WLLL _ ❑GEonlyy7CAL WELL If ❑ SO,L��� <br /> ❑OESTRVCTION � P <br /> INTFNbLD USE PyPE OF._WELL CONf7 RUC flO <br /> N iPECIFICAiIONi �! � <br /> ❑INDUSTRIAL ❑OPEN somm <br /> DIA OF WELL EXCAVATION DIA OF CONbUCTORCASRIO <br /> ❑DOEEESTfCTf11VATE ❑GRAVEL PACKISI;E TYPE OF CASINCIMIEEUPVC D <br /> ❑NS"CIMONICIPAL ❑DInVEN —= - DIA OF WELL CASINO O <br /> DEMIf OF ORO VT SEALfPEC1FICATEON r <br /> ❑mRIOATgN1A0 ❑OTHER GROUT SEAL INSTALLED eY ( "^ <br /> 3 MONITONNO r--t OROUt SRANp HAMS If()({ E <br /> GROVT SEALIVMrro ❑yw ❑'Ha CONCRETE PED Si <br /> f E AL SY biStlEfL❑Y.. He S <br /> Al+pgoK DEPTH LOCKING CHFSTEn soxISTOVE%PE <br /> PKOfbf[b CONSTRVCnoKMMtUNO Mrr"GtI MUD ROTARr d <br /> AIR fOTARr AUCER,� _CABLE <br /> OTHER <br /> f HE9ESY CERTIFY THAT I HAVE fElEPAnEP THIS ATTLICATION ANO 7HAT THE WOR(WILL HE DONE IN ACCORDANCE WITH SAN JOA MH COVNTY OI0INANCEB STATE LAWS ANp M1VL[S AND <br /> FlEGtrUTIONS OF THE BAN JOAOVIN COUNTY HOME OWNER DR LICE" <br /> @EO ADEM S SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT 1EE THE PE170PIMANCE OF Tiff Wpq(FOR W711CH <br /> TIES PERMIT IS fS@UEb I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN•COMPTNSATION LAWS OF CALIFORNIA, CONTRACTOR S HIRING OR fue{OMRACTINO SIGNATIRV:CERTIFIES <br /> THE FOLLOWING 1 CERTIFY THAT IN Tiff PERFORMANCE OE THE WORK TOR Vwocm THIS Tjnmrr is 1BsVED 1 SHAH EMPLOY RECTORS SUBJECT TO SOCONT M S IHG SIO MACH ULWT OF <br /> CAIKORMA @FIE APPIACiIKT MUST CALL 21 FIOI11S IM ADVANCE Fon ALL AFOVIn(O IN@KC nONi AT"o,1 qS ,,] COMKE7E OMWIFfG A7 EDWER AREA ITONb[b <br /> J TNI. /� . -I;�SS` D.e•__�1 5,� ?'� <br /> PLOT PLAN <br /> 1M.w ro Sa.lel fic I.J le r)r • �� <br /> 1 NAMER OF STREETS OR MHOS NEAREST TO OR BOUHOING Tiff PYOPEnTY <br /> 2 OUTLINE of TILE FMPERTY OMNO DIMENSIONS AND NORTH Dif1ECT1ON LOCATION OF HOVSE SEWAGE DISPOSAL tYTTEM OR FROPD&EO <br /> WMENBKMFD OUTUDIFO AND LOCATION OF ALL EXIBnHG AND PROPOSED tXPARCON OF SEWAGE DISPOSAL SYSTEM@ <br /> STRUCTURESt INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS S LOCATION OF WELL@ WM4W MOIUe OF ONE HUNDRED FIFTY FR <br /> Off TIIE PROPERTY On AOJORNINO PROPERTY <br /> Fll <br /> I < < c a <br /> i < c � � } r • ` <br /> s/I)a✓� <br /> /� ; <br /> -� '�D�MTASENT Vs!ONLY <br /> AFMIFnIen AFfw,t.i ar • ON. _o ,5 !I` <br /> A r <br /> a.A IRgeelleR er D.f. <br /> aefleR ar � L <br /> oaKruetlen Mr.PFPIPFn SY + DNS ^ ,� '. <br /> OemmarK. /L <br /> ACC <br /> OLINnNO ONLY; AIDE FACP 4 n 'r <br /> PE COPES FEL LIFO AMOUKT RmTTE9 CHECItilmASH RECFPlEO■Y DAT! <br /> ` Pa"T/SOWICE REoUEBT I wow tHYOICE _ <br /> Pub Health Sery EmAro 173(1/97) <br /> r, <br /> J� <br />