Laserfiche WebLink
+� APPLICATION FOR WELLIPUMP PERMIT <br /> s I SAN JOAMCOUNTY PUBLIC HEALTH SERVICES <br /> E MENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N.SAN JOAOUIN ST,STOCKTON,CA 96201388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICompIEM iR TJ4FNetFR <br /> APFUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE MR,DESCRIBED.THIS APRICATION I6 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.111 S.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY MSUC HEALTH SERVICES.EN RRDNMEMK HEALTH DARS10N. <br /> JOB ADDRESSM A[PNI,r0l'(snCI1 51k /!�G IS �W PK CTYJS-tr-/K�'vrl P�AR�CcraS(I$I1RAPNs <br /> EIJr LN11Il ✓HETI ✓II ADDRESS ZDFX TV�3, «�/Y-In/I ITIY a�"PHONE/' V1�/S�vlb� <br /> OWNERS NAM/EpA yy♦♦�� j� //�.., l���//�I yI I. (�,_.,��u1 `IV1R' l <br /> CONTRACTORVn(frI' IL I✓IGVI,✓drr e7jlilil 1n� ADDRESP702t y'II✓/POT 'S-1 U., l�f[�� RHONE/µ <br /> SUBCONTRACTOR I LLW✓✓ N'Y pldAnul ADORES,grin(W (rvd(Uf,� USI, L a PHONE.WST- <br /> TYPE OF WH1/PUMP: NEW WELL ❑PEP.ACEMEM V.'ELL MONITORING VhLL IM1U 78 t ❑oTHEfl <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPNR tAW-M ❑VAPOR EXTRACTION WELL i J <br /> ❑N� N.P. DEPTH RUMP SET---FT. FIRST WATER LEVEL 0 <br /> RYIPE OF PUMP) <br /> 0DUTAF6ERVICE VhLL ❑GEORfi'SICR WFlIi 601E BORN, S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL COX6TPUCTIOM iPECIFCAT10N8 ! A <br /> ❑ INOU6TAvL ❑OPEN BOTTOM DWOFWELLE LAVATION / DIA.OF CONDUCTOR CASING D <br /> ❑WMESTICI VATE ❑GROVEL PACXSRE )Z� TYPE OF CASINGMTEEIJPVCf� DA.OF WELL CASING D <br /> ❑WBUCAIUNICIPK ❑DWVEN DEPTH OF GROUT SEAL )✓ SPECIFICATION R <br /> E,❑.,/IWUGATIONIAG ❑ LLE <br /> OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> 93MONRORNG _ i I GROUT SEAL PIMPED:❑Ys ONe CONCPETEPEDESTALBYOWUEP:IlY- 13M S <br /> YAMOX.DEPTH LOCKING CHESTER 90XISTOVE PTFE 'S <br /> PROPOSED CONSTRUCMI NRWNO METHOD: MUD WTAW AIR ROTARY AUGER X CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WONT MUL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGUUTON6 OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LILL <br /> LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL HOT FMMOY PERSONS SUBJECTTO WMANIAN'S COMPENSATRN LAW60F CAUFOPNIA•COWMCTOR'6HIRNGORSUBLONTMC WAGNATUMCERTIRES <br /> THE FOLLDWING: 'I CEWIFT THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERNI T IS ISSUED.I SHNL EMPLOY PERSONS SUBJECT TO W OfFRAN'S COMPpfATRN IAWS OF <br /> CAUF0RMA.IFN EAPPLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSJP/K-IIO/rF/f AT IZDB/IM�f^n.COMPLETE DRAWANG AT LOWER AREA 7/-,-7P <br /> /7 <br /> / ROT PLAN Ignv W Wel SMOB to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO 09 SOUNDING THE PROPERTY. A.LOCATION OF HOUSE EWA EEWAGE SYSTEMS.SYSTEM OR RpfO,EO <br /> 3. OUTLINE OF THE P QPERTY.GMNG DIMENSIONS AND NORTH DIRECTION, EXPANSION F SEWAGE g6Po RADIUS <br /> OF ON <br /> 3.DIMENSIONED OUTUNE6 LAID LOCATION OF ALL EXISTING AND PPOOSED S.LOCAPOR OF WELLS ADJOWITHIINING <br /> ING OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A6 PATIOS,DNVEWAYS,AND WA1X6. ON THE PROPERTY OR ADJOINING PHOFERTT. <br /> 'sok. Els 7til��_ Il�sizllt oi't Navy <br /> y . 4ilf <br /> I <br /> --A- Ste pk' ctzd M/ F �Z+ <br /> LGfi.S.: <br /> DEPARTMENT USE ONLY I �1 <br /> L <br /> Aoor�otleo Aowqutl Br �!+` M�' . <br /> Grout lmR m By wtv P,mp Lup:tion BV DAN <br /> D-I—Oon Ir.Pstbn Br D. <br /> C— <br /> ' AIDE FACE <br /> PE COOFE FEE INFO AMOUNT REMITTED CXECIIIICP6X RKDVFD BY GATE PFRATRIUMCE REQUEST HUMH91 INVOICE <br />