Laserfiche WebLink
OPLICATION FOR)�MLUPUMP PERM oP Y <br /> SAN L,JAOUIN COUN UBLIC HEALTH SEkvwES fitibc <br /> ENVIRONMENTAL HEALTH DIVISION 2��a <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> pP ,I7vf,1G\� <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpIBu In 711pO4BM) Nxi <br /> APPLICATION IS HFRE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE I WIT <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTYUB <br /> PLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. J <br /> JOB ADDRESS/OR APN/ 51 SI P4ei r/C 4V9 iVtiE CITY 5"TCTG I�rC//Y PARCELSIZEIAMN <br /> OWNER'S NAME S^1N�G%✓lsJtlrn/PIE/7•^g e" <'C.F "ORE68 S'y�YE/!'Fs'JJli' -y PHDNER z�% <br /> CONTRACTOR �1�/max E�rLC //L•G. ADDRESS 2t�z J%s• LI��jUCF- 7�SfnT/ PHONE Ms <br /> y61 <br /> 57E7ccrtin/ 7 <br /> SUBCONTRACTOR ADDRESS UCI PHONE• <br /> TYPE OF WELUPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL l J <br /> ❑N.11 A".1, N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> (TYPE OF MMPIy <br /> ❑ OMIT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL �601L BORING ��JGT��/A�4 B <br /> ❑DESTRUCTION: -7Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A - <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CAGING D <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R <br /> !1R+yIRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> LJMOMTOnINO GROUT SEAL PUMPED: ❑Y. [IN. CONCRETEPEDESTALBYORILLER:❑Y. ON. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTO VE PIPE 5 <br /> PROPOSED CONSTRUCTIONNPoLUNG METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> 71116 PERMIT IB ISSUED.I SHALL NOT EMPLOY PERSONS S90JECT TO WORWAN'6 COMPENSATION LAWS OF CAUFOIWIA.- CONTRACTOR'S HIRING On SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN TIE PERfORMA!CE Of THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS 1 ADVANCE On ALL REQUIRED INSPECTIONS AT 120814603123. COMPLETE DRAWING AT LOWER AREA 14101AD <br /> BlPned X -j& deato Tllls <br /> PLOT 4N to,.le SeNel Bc.l. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PHOr'U6ED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> tlyi✓'y,Fo�t.'�YE�1.' ✓'f Oil /rU"C... <br /> T ENT USE ONLY I I 3 <br /> A111.0en AseePted By D.I. <br /> D.le Pump IrnPeellen By <br /> Grout lmoecSen By <br /> De.Mnsllen 0nneelbn By �� <br /> commNe.: L� <br /> ACCOUNTING ONLY: NDP FACE <br /> PE CODES ITEE IN-0 AMOUNT REMI ED CHECK (CASH RECEIVED BY DATE PETWMTREAVICE REOUE NUMBER INVOICE <br /> �s� o L <br /> � <br /> 353 3 <br /> PUh.Health Sam.-Enviro.173(1197) <br /> U <br />