FIELD DOCUMENTS_1998-2000 - Laserfiche WebLink

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PPLICATION FOR WELUPUMP PERMIT ' S AQUIN COUNTY PUBLIC HEALTH SES rENVIRONMENTAL HEALTH DIVISIO CSU N fi 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Z - (RMIT 468-3420 dy 0 R I G/�-I L� N3M•REFUNUASLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED � ICGmp1119 In TRIpILe9ltl /�� APPLICATION IS Y DE EL MADE TO TNF BAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT T/RIf`CNAPFEfl/9/.1115/.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH (p�ORROGN.t� JOBADDRESSIOHAPN/may 11;Neo)/J ( P TF(� CITY��C��ivr PARCEL BIa-15t M 3e.•F'F D Cle ne e-.,oto.,{ Csce Ds) /9,e0 P.well .sri is r=ioP� OWNER'S HARASS/� � R a r / F C4Rw�AODRE88_F',,..a.•N i/¢. Si4 94608• �8.?J NE tS�a PHO - --7JL—Y– CONTRACTOR ADDRESS LK:I PHONE– �u T r awc d. SVS CONTRACTOR �pao S' ADDn[ee/NarY/tip: CF3 4YS63 IICI /a5G,Yo7 —� rrgNE.Sio-3iS-s8/ TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR098-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑ (TYPE OF PUMPI pR •1v N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL/ ® SOILBORIW S 11 DESTRUCTION: INTENDED jgg TYPE OF WELL CONSTRVCTION 6PECIFICATIOHt 11 13 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL E%LAVATION .�-[„N CrypS DIA.OF CONDUCTOR CASING A/�/.J 0 ❑ DOMESPURUC LCR ICIPAL ❑GRAVEL PACKISI2E TYPE OF CASINO/STEELWC A/lF7 DIA.OF WELL CASING /LJ A9 D ❑ RIBUCRAVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �'O�i2/ lJOI�{'� SPECIFICATION CHP W p ,i>�- 60 A I f % R ❑ IRRIGATION/AG ®OTHER GROUT SEAL INSTALLED BY CI�A1T_T'CGe fO/" GROUT BRAND NAME Al' q E ❑ MONITOMW GROUT SEAL PIMPED: ®Y. [IN. CONCRETE PEDESTAL BY DRILLER:Ely. ❑N. ,L/%A S /� APPROX.DEPTH (�"5-t/ / LOCKING CHESTER BOX/STOVE PPE A/ZQ // s PROPOSED CONGMUOTIONgNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER LIP % �USIy I HEASBY CERTIFY THAT 11HAVE PREPARED THIS APPUCATK N ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,ISI/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COWRACTOR'S HW NO OR SU"O WRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT I THE ORMANCE OF T E WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: THE A CANT CALL A qUM IN ADV FOR ALL REQUIRED INSPECTIO N S AT 120914011 1� COMPLETE DRAWING AT LOWER AREA PROVID Off�../� L/,1/ st.n X �Tllle lle- �/D IPA.T Md NgQP/' D•t• lV T U POT PAN ID,•w to Sa•I•I ec•b 't. 1. NAMES OF STREETS OR ROADS NEARS T TO OR BOUNCING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On pMMSED 2. OMLINE OF THE PKIERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. M R p 17 f�c� a�► e c�. PAYMENT LpEE�,4'>• ^.,.e—f'". DEPARTMENT USE ONLY APPlleetlen Aeewled BY Dots_ 0O fhN C,A CL)IIPf O,eNI Impmllen OL By 0010 Porn.InlP•.Gen By PUBLIC HEALTH SERVICES EPIVlfY1PIMEl el uF42FN DIVISION De•mcllen ImPplbn By ACCOUNTING ONLY: MDI FAC! PE CODES FEE INFO AMOUNT REMITTED CHECIUMAIN RECEIVED BY DATEFEWAITRFRVICE REQUEST NUMSDI INVOICE 2`l0 3 zc� CES 3-Cxl�4 D/So/ Pub.Health Sew.-Enviro.173(1/97)