Laserfiche WebLink
SA&APPLICATION FOR WELL/PUMP PERMIT <br /> AQUIN COUNTY PUBLIC HEALTH SES <br /> ENVIRONMENTAL HEALTH DIVISIONNW <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> [COMPIe <br /> n TrIIIkmf.I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTINOffin INSTALL THE WOR(DESCRIBED.T1119 APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMEN-E TITLF�CHAPTER B-1/1116.3/AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADOgE89/OR APNI '37& /.�N(�OIYJ ! 1lLe – (1//� <br /> C@�1%,�9 'FJ y �I 4, De N CITY TOC PARCEL RIMAPLJE <br /> OWNER NAME /G—T�"m a-IcLT a ua^�(S CDS) /900 7�owe11 aLree <br /> do .f K AubgEse_Ern_ ,a Cq 9y� <br /> CONTACTOR 9 /8a7 RHONE IS/2-i ,s7-y�O <br /> / u ADDRESS Me <br /> SUB COMMCTOR��jpO Tra36s (,(J%9wam fir. PHONE <br /> ADDnEse_Steo_4 fon CA 9Saor Ext eS7-S/ad68 <br /> PHONE Ia09-'f6S-,pJ <br /> TYPE OF WEUJPUMP� ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL S <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> I� ❑ CROSSCONNECT REPAIR <br /> /F ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑ <br /> RYPE OF PUMN Repelr N.P. DEPTH PUMP SET 0--L FT, FIRST WATER LEVEL <br /> ❑ OW'CF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ G <br /> ❑DESTRUCTION: 601E BORING B <br /> INTENDED VBE TYPE OF WELL <br /> 6PECIFICATIONB <br /> INDUSTRIAL ❑OPEN BOTTOM CONSTRUCTION q 4 <br /> 11DOMESTICR'nIVATE ®GRAVEL PACK/SIZE CIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASINO / lAg <br /> 11 PURUCMUNICIPAL 11 DRIVEN TYPEOFCASINO/STEEIVVC JCI{ //0 PYt DIA.OF WELL CASINO D <br /> ❑ WRIOAigN/AO ❑OTHER DEPTH OF GROUT SEAL T ..30� SPECIFICATION <br /> GROUT SEAL INSTALLED BY .0 r/ISP r R <br /> AP MONITORING OIgVT BARN NAME&CQL�p��_t E <br /> APPROX.DEPTH <br /> GEAL P <br /> 90 (INOUT SM ®Yr ❑/S CONCRETE PEDESTAL BY DNLLEn!®Vee 11 N. 5 <br /> PROPOSED CONSTRUCHDItW <br /> ON/ NG METHOD: MUD ROTARY LOCKING CHESTER BOX/STOVE PIPEUP.S <br /> AIR ROTARY AUGER___CABLE OTHER 5 <br /> 1 HRE <br /> EBY CERTIFY T{IAT I HAVE PREPARED THIS APPLJCATION AND THAT THE WpR(WILL BE DONE IN ACCORDANCE WITH SAN JOADVIN COUNFY ON)INANCES,STATE UW6,AND RULER AND <br /> REGULATIONS OF THE RAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENPB SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEN CMANCE E THE WON(FOR SAND <br /> THIS OLLO IR ISSUED,I RIIALL NOT EMPLOY PERSONS SUBJECT TO WORM <br /> COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIM OR SUS.COmM' CF IND SIGNATURE E WORKCERWHICH <br /> TIFIES <br /> THE FOLLOWING: •I APPLICANT <br /> THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH TIIIB PERMIT IS ISSUED,1 BHA EMPLOY PERSONS SUBJECT TOUR CONT AC IND SA UWB OF <br /> CAUFOIINIA.' THE A15)PPDCANT MUtT CALL N!I t UKADVANCE FOR ALL REOURED INtMPONt AT ISOt140SA 23. COMPLETE DRAWING AT LOWER AREA PRoVI ED. <br /> % TIUe ' <br /> D.I. Z <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING iPLOT P!ENP M.1.�Jel Beae •Ie <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE D19MOAL SYSTEM On PR01`OSED <br /> J.STRUCDIMENSTURES. <br /> OUTLINES INCLUDING <br /> AND LOCATION OF ALL AS FANO AND PROPV BEV EXPANSION OF SEWAGE DISPOSAL SYSTEMB, <br /> 6TRVCTVREB.INCLVDINO COVERED AREAS SUCH A9 PATIOS,DRIVEWAYS,AND WAMS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED PFTY ET, <br /> ON THE PROPERTY OR ADJOINING PnopEnTy. <br /> m .9 fJ �tcL c�► ect. <br /> .......... <br /> ............. <br /> DEPARTMENT USE ONLY <br /> APPIbellee A««IM BY Deb 3 -z6-9 g <br /> Gm VI ImP«Sen By Arm <br /> D•I^ PrmiP m.P«Ilse ey <br /> b«Inclbn Imn«Ue BY DHe <br /> LI n �1 Dele <br /> CemmdlH: 0 U. ,F ANMMAV140 <br /> ACCOUNTING ONLY: AIDS <br /> FAG <br /> PE CODEC FEE INFO AMOUNT REMITTED CHECKtM.ASH RECEIVED BY DATE <br /> ♦ , PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 1�u U °`J 3 p &aa 8 <br /> nl5 G <br /> Pub.Health SEN.-Enviro.173(1/97) <br />