Laserfiche WebLink
IArr1aL.#A I lvn run wcLL./rumr YtHMIT <br /> S f&OAQUIN COUNTY PUBLIC HEALTH SfPICES <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> ` 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplkelel <br /> APPLICATIONISHIM BY MADE TO THE SAN JOAQUIN COUNTY FOR-A PERMIT TO CONSTRUCT ANDMII INSTALL THE WOW DESCRIBED.THIS APPLICATION IS CCOMMIANCE JOAQUIN COUNTY DEVELOPMENT TRUE;CHAPTER 91116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEJOB ADORE89roft APN/�76 4iA7LF0//u �P AJ e.Y CITY �J�'U r✓>'1 PARCEL 6IZ, cArcee..{s SZIM /ffxJ orae/ y.�eY /.T Fe. <br /> OWNER'S NAMEe iV /dT !� d hG LlU e, D nJ ADDRESS Ftic� ri`//� ('q YJ140T'-/Q.�7 <br /> CONTRACTOR - ADDRESS LOCI PHONE <br /> SUB CONTRACT <br /> In PC !'lLwr 1v ADDRESS /ae.4 Fe PCIq 9�OS UCIC.S7-S/T16DPHOHEIT09-S'G,s-P: <br /> TYPE OF WELL"MP: p,,q� NEW WELL ❑ REPIACEMENT WEiI ICI MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> /V A ❑New❑Rb .I, H.P. DEPTH PUMP 6E �//�FT. FIRST WATER LEVEL 0 <br /> TYPE OF PUMPI <br /> ❑ OUF4)F-SERVICE WELL ❑ AEOPMYOICAL WELL/ ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL I❑OPENSOTTOM DIA.OF WELL EXCAVATION r1 /O�r 1f DIA.OF CONDUCTOR CASING A)19 D <br /> 11DOMESTICRRUIgq <br /> VATE W GRAVEL PACK/SIZE i0` TYPE OF CASINO/STEEVP SCA VO ITP_ DIA.OF WELL CASING D <br /> ❑ PUBUCRAUMMIPAL ❑GtowN DEPTH OF GROUT SEAL .SDI SPECIFICATION A <br /> ❑ mRIGATMN/AG ❑OTHER GPDUT SEAL INSTALLED BY b,-i Ile r OROIT BRAND NAME AAPa L CIqe OPL e"t E <br /> ® MONITORING Gn unr SEAL PUMPED: ®Y.. LI N. CONCRETEPEOESTALBYDRILLERl ❑N. 5 <br /> APPROX.DEPTH 80 - LOCKING CHESTER BOX/STOVE PIPE S <br /> PROP06FD CONSTRUOT10NI RING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES,.FATE LAWB,ANG RULE.ANO <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT INTHE PERFORMANCE OF THE WOW FOR WTSCN <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOVINQ: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUI I IN ADVANCE FOR ALL REQUIRED INRECTIONS AT 12061eeeb/22. COMPLETE OSAWING AT LOWER AREA mIOVIDED. <br /> nn. Si�C �rcl Pc T/ /la Naar!' <br /> i <br /> PLOT PLAN ICI.«1.6cw1 BP.Ia •I. , .. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR INWPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND MONTH DIRECTION. EXPANSION OF SEWADE DISPOSAL SYSTEMS. _ <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PIIOPERIY. <br /> Mapf�a a� e CC,. II <br /> rt <br /> DEPARTMENT USE ONLY <br /> APPIIP.RPn AccVt. BY DU. l'O/ O A,.. <br /> O'.,n ImPxOen BY TIM. Pv p In.P.11.n BY D.ta <br /> 61 <br /> De.tncB.n I—rP h.n BY Da. <br /> cPmmo-,H: IX,7-L <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REASTTED CHECK/!CASH RECBVEO BY DATE PBVAITIeFAN INVOICE <br /> 3oqqS- �P <br /> 55 Z <br /> Pub.Health Sere.-Enviro.173(1/97) <br />