Laserfiche WebLink
f <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,.• ENVIRONMENTAL HEALTH DIVISION <br /> r 3 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 488-3420 <br /> �0.5 NOR-REFD11DARif PERMIT HFIRES 1 YEA# FROM DATE ISSUED k <br /> �-( ICgmpMN M illptksul <br /> APT'LICATION I9 IR 9Y MA Te T1tE CAN JOAQUIN COVNTY FOR A GfFOAtt TO CONSTRUCT AMOIOR IN91AIL TiIE WORK DEBCMAFD.THIS APPLICATION 19 MADE IN COMPLIANCE WHIP SAN <br /> JOAQUIN COUNTY CfVFtQ,['MENT T LE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MILK:HEALT11 eERV10E9,WARONINENTAL HEALTH OMetom. <br /> JOB AOOAZI)WOR APHI_ _„[:i�S_ .LP-:t}.It f-:��r��._f lv -I'� rV f� '�_�.�'C,�,CtRY PARCEL SIZElAPNI_ ����j <br /> 0WNtn'S NAME_ '.a AOOAEBe� �C C'+ <br /> "Hone Prx <br /> cdMRAereq C — AGGAf9e �S�1�•� 1 S �'.sldf —uc zg "s Mlorn fjz!' --Tll-'&v <br /> AtM CONTRACTOR ADDRESS "Cf PHONE <br /> TYPE OF WFLLAstIMps (J NEW WELL ❑ REPLACEMEITT WELL ❑ MQNIFOMM WELL I ❑ OTHER <br /> ` ❑ INFITALI.ATION ❑WELL eYBTEM IMPAIR ❑ CAOB9,CONNECT REP A!n ❑ VAPOR EX TRACTION WELL 1 <br /> J <br /> E)Now 0 Raealr H.P. DEPTH FVMp BET F'F. FIRST WATER LEVEL <br /> H YFE OF PVMPI G <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL► BOR gamma <br /> A <br /> ❑bEBTIItTCYION: <br /> INIEl10ED.VSE YPe O _ COPTe7pI1C110N SPECIFIC (IONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM A <br /> DIA,OF WELL EXCAVATIO ' 1.1 t- � DIA-OF CONDUCTOR CASINO <br /> ❑DOMEeTICATgVAiE ❑QRAVEt PACKlgIZE D <br /> TYPE OF CAMMOMI EE1/TNC DIA.OF WELL CASING <br /> ❑ R/SLICtMVN1CIPA- ❑OIeVEN MPTN OF GROUT SEAL' 't- _ n <br /> ❑ tRAIGATIONlAO ❑OTHER SPECIFICATION �\rl y A <br /> GROUT SEAL INSTALLED BY ORGVT BRAND HAMS <br /> ❑ MONID ni- GROUT SEAL P UMMO:�Ya• ❑Ns E <br /> CONCRETE PEDESTAL BY DnILLEq: Y. ❑No S <br /> APFRDIf,aE1TN �� .�.+) <br /> �. LOCKINO CHESTER BOXMOVE PIPE . <br /> P7tOHOSED Ce"TALMHOMM"LLIMD METHOD: MUb ROTARY S + <br /> AMI ROTARY _ AUGER CABLE <br /> OTHER T._ <br /> I HfBY CERTIFY iF1AT 1!LAVE PREpAftEp THIS ApPLICAT1pN AND THAT THE WORL WILL BE DONE PN ACCOltOANCE 1NlTPI 6AH JOAQUtlP COUNTY ORQINANCEe,9TATf LAWS,AND RULER AMC <br /> nEGULA rr I OF T14E SAN JOA"or COUNTY, HOME OWNER OR LICEHSEQ AGENT'S SIGNATURE CERTIt1Ee THE FOLLO%PA".•1 CERTIFY THAT IN THE PERFORMANCE dF THE WORK FOR WHICH <br /> THIS OLLOV iS ISSUED,1 9ifALL NGT EMPLOY PERM SUBJECT TO WORKAIAN'e CORIPENeATIOM LAWS OF CALIFORNIA.- CONTRACTOR'S HAVNQ OR eUBCONTRACiBIO SKRNATURE CEATKTE6 <br /> THE FOLLOWIMi '!CERTIFY T 1YORSIANCE Of THF WORK FDA VIMCFY THIS PERMIT T9 Ie6Ufb,T SHALL EMPLOY PERSONS SUBJECT R B-CONT M'e COMPEMSATIOM LAWS IF <br /> CAUFD _ THE APPUCA UST URS HF ADVANOe"NAIL REQVptED lNSPEC T{DN•AT 1}pSI IgyT7g. COMP;E'TE DRAWING AT LOWER AREA P'pONbfO. <br /> S10na'd k SWT <br /> THt• <br /> bat• <br /> T. HAA1Ee OF eT F'LOT FLAN(prow to So.I.I.Be.I. 't• <br /> REE7B OR ROAOe NEAREST TO on no <br /> UNOMM TINE PROPERTY. li, LOCATION bF{ROUSE eEWAQE DISPOSAL SYSTEM OA PAaP08ED <br /> 2, ORL"NS'OF THE FFUW,@ Y, LOCA'EMMONS AND NORTH DIRECTION- <br /> • HBtDllfb OUTLINE•AND LOCATK7M <br /> OF ALC FXItRTINO AND PnOPOOD EXPANSION OF BEWAQE DISPOSAL vVeltMe. <br /> DING COVERED AREAS OW"AS PATPOO.C"VEWAYe,AND WALKS. e. LOCATION OF WELLS WTn"RAOR1g OF ONE HUNDAE <br /> ON THE PROPERFY OR ADJORAMO PROpoTIY. O FIFTY FT. <br /> :. .. . . . <br /> i <br /> .;....::.. <br /> ' Y <br /> i.. <br /> ................:... . <br /> DVAftf-ENT USE a{ILY <br /> ' AppS.Nlen Ao••Oted ey - <br /> 1.w4 hwp—tlen Br bat• H» �►,y �f_ <br /> bats��i1anP Pnapaalfer,By �•— <br /> i, Dat. <br /> DMu,rllen lrwp.ell•n Ry _ <br /> b.ta <br /> C•1nm[rea: e- I <br /> dT <br /> I <br /> { <br /> ACCOUNTING ONLY; NOF _ <br /> Face <br /> PE caDEe FEE INFO AMatMll REMITTED C1IECKIlCASN RECovED BY DATE <br /> PFfIM1TleERVICE REGLIESi NUMee1 INVOICE <br /> Pub Health Serv.-Envfrd.173(1197) <br />