Laserfiche WebLink
4PPLICATION FOR WELL,IPUMP PERMIT <br /> SAfWJAOUIN COUNTY PUBLIC HEALTH SEwwCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICEmplot@ In TRlplicetel <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOlOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITO SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DR71910N, <br /> JOS ADDRESSIOR APmo 22-14841 5.{��y-t AAA S�-_ CITY�(�(JV) - f �_- PARCEL SIZFJAPN/ p^� <br /> OWNER'S NAME, �V.�jj�_ PJ'fCAI F�Y4-il���-1{C4 ADDRESS 72L`" -[ ]- 1. S4-U+ PHONE, 6 JT- 16t 3 <br /> CONTRACTOR 5pw e\ - TL(-610(Ogy COr�C�1R1�Y�Gr ADDRESS 12-GO Y1I� '61r. �r 1 q <br /> �p LIC, J l Q�CJrI_ PI}OHE/ �-�1/9'LrZ�z,rt� <br /> SUB CONTRACTOR �\ (..1n Ev��l Y't'7v\u�E.v�-CQ ADDRESS ✓T9 5�1 S N tl.q- LICE(43 W5 PHONE!}T?L 3 !�+ <br /> I. <br /> TYPE OF WELLIPUMPNW <br /> : ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, <br /> - 9.52520OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑New❑Repdr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> {TYPE OF PUMPI <br /> © OUT•OFSEFIME WELL ❑ OEOP14YSIC AL WELL t W SOIL @OTBNG R) <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCIRON SPECIFICATIONG J A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION 100 DIA.OF CONDUCTOR CASINO xO <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/BTFELII'VC NIA DIA,OF WELL CASINO �� a <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 2)0 jt" SPECIFICATION gyp. y'` _ R <br /> 11RRI <br /> IOATONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT ERANO NAME k rTt Lltii�'w E' <br /> w—NITORINO GROUT SEAL PUMPED: ❑Y. }a No CONCRETE PEDESTAL BY DRILLER:❑Yea J Nn S <br /> APPROX.DEPTH ,e+ LOCKING CHESTER EOx/STOVE RPE 5 <br /> PROPOSED CONETRUCT}ONIMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HMRY CERTIFY THAT I PIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REQULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOW NG:•I CERTIFY THAT IN THE PERITORtMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'@ HIRING OR SUBCONTRACTING SIGNATURE CERtIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IE ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUPRED INIIPWT/ONS AT"1411141IN <br /> -9422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ne <br /> Slyd x L 1C.rI JYI./YLl_� -- '----- Tu1., J� /19 a_e.�/LI D•,. '7�/� �9? <br /> PLOT MN Shaw to Sexy Sade 'to <br /> 1, NAMES OF STREETS OR ROAD@ NEAREST TO OR SOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> d. DIMENSIONED OUTLINES AND LOCATION OF ALL ExISTWO AND PROPOSED S. LOCATION OF WELL@ W TT18N RADIUS OF ONE HUNDRED FIFTY ft. <br /> STRUCTURE&,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 97-739-A2 <br /> NUNBfR <br /> oc <br /> u <br /> m S. SEVENTH STREET mo <br /> C A C) - <br /> N YV <br /> Iia K> V7 C-) '. <br /> d m a I 7 n <br /> @ ' :32 Z - <br /> m Z <br /> +m m <br /> O <br /> gg- q N A a I p p O <br /> � <br /> - - <br /> _ 3� � <br /> A <br /> b <br /> nc: zoc <br /> < b T <br /> 1 D b m <br /> m � �➢r D56 <br /> mA m i� r <br /> r � m M frI I <br /> �mozNz my m E <br /> z A Z <br /> �o Z p Y <br /> u ?D m ro(7v <br /> DEPAIITMENT VSE ONLY R <br /> Aeplicatlan Aaoept.t BY Data V •5� MN <br /> Olsut Rnrpeallen Sy <br /> Data Fuanp hweatIon Ey DNa <br /> DerUt.Hen ImpaoOen BY nate <br /> CemmenPr: � � O v <br /> ACCOUNTINO ONLY: AID, FACT <br /> 1PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED EY DATE PER MITISERVICE REOUEST NUMBER INVOICE <br /> 36 01 1fq MO ­ 132- G <br /> Pub.Health Sam-Enviro.173(1197) <br />