Laserfiche WebLink
SANIPLICATION FOR WELL/PUMP PERMIT <br /> LQUIN COUNTY PUBLIC HEALTH SEOES w <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 A <br /> (209) 468-3420 LV,: <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED / L <br /> lCom <br /> lets <br /> APPLICATION IS IIEPE By MAGE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSP UCTIAMMn INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMRIANCE NRTII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITL/E�CNAPTER 9-11116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SEANCES,ENVIRONMENTAL HEALTH DSMsBSION. <br /> JOB AODRE88roR APN/c// Ip -/C J/•/(/ I hJ ( P N2�G' F— CITY S�C/C 7T/N n �1/-�QB-R/�o.2/� <br /> Ss'1'F�IN 'Dr GI@4u, PARCEL 812EJAPNI Ru <br /> OWNER'S NAME CA D2j,a.1d T. G�r0.c[ 'Tim �u'��S �S ZYC�DS� /900 7�owEJ1 �-re <br /> -•/ L— F.-: I�ADOREee EFY CA 9y6o8 -/Sd7 PHONEs6/D-/aS,7-yrnn <br /> CONTRACTOR , T ADDRESS <br /> UCI PHPOHNOEN/ <br /> Bus CONTMCTOR-' QpcjII -GL LIi9a Dr <br /> ADDRESS E <br /> 565-87. <br /> TYPE OF WEUJPUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CI1088CONIACTREPAIR ❑ VAPOR EXTRACTION WELL <br /> 11N ❑Nw R.polr H.P. DEPTH PUMP BET //N FT, FIRST WATER LEVEL <br /> RYPE OF MMPI * <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORIM S <br /> El DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATIONAY/ <br /> DIA.OF CONDUCTOR CASING /1l/A p <br /> ❑ MMESTM MVATE ®GRAVEL PACK/SIZE # /O TYPE OF CASING/STEELIPVC Sf# /VO YI/C VIA.OF WELL CASING <br /> 11PUBUC/AVNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ,.3D/ p <br /> 814CIFbATbN 1 R <br /> ❑ WAIGATIONIAO 11 OTHER OROUTBEALINSTALLED BY aBMW BRANDNAME_&yaL cement- £ <br /> AP MONITONNO n GROUT SEAL PUMPED: ®Ys [I No CONCRETEPEDESTALBYDRMER:®Y« [IN. <br /> APPROX.DEPTH Y / LOCKING CHESTER BOX/STOVE PPE )'-VPS 5 <br /> PROPOSED CONSTRWNON/ UJNG METHOD: MUD ROTARY AIR ROTARY AUGER_ � CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOVIN COUNTY. HOME OWNER OR LICENSED AGENT-9 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF TNM WORK FOR WNtCH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PEnSON6 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COWMCTOR'S HIRING OR SUBCONTRACTING SIONAT CERTIFIES <br /> TNF FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP6NZAP LAWS OF <br /> CAUFOIWIA: THE APPLICANT MUST CALL 24 MUM IN ADVANCE POR ALL REQUIREDppINi//MMNS AT I20II tp-f1/2,�2. COMPLETE DRAWING AT LOWER AREA P oVDM. <br /> SIPMd TRIS c)%7� �!-0�P /'I Q�rl4 a P y— Dote <br /> % - It `l <br /> POT PAN to,.to e..le1 Seel. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OP PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND MATH DIRECTION. EXPANSION OF$MACE DISPOSAL BYBTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVEREDAREASSUCH AS PATIOS,I)MVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> m '9jo L L CY- c' In ct, <br /> - • pig-z <br /> DEPARTMENT USE ONLY <br /> ApP11e.Ilen AeeepteA <br /> Det. Mu <br /> Or.N Imv..Gen 0' Dote Pmp ImYeell.n BY Dae <br /> DntRttlen UnpeeBen 8Y <br /> /Lnot. <br /> U7 <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH "MOVED BY DATE PETWIT/BDIVICE REQUEST NUMBER INVOICE <br /> oft <br /> / Z <br /> ?,b <br /> Pub.Health Saw.-Enviro.173(1197) <br />