Laserfiche WebLink
APPLICATION FOR WELD UMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEAL DIVISION k <br /> PIV.BOX 388,304 EAST WEBER AVEN JE,STOCKTON,-CA VWDI1 8 <br /> 12091 488.342 <br /> NON-REFUNDABLE PERMIT EXPIRES! T AR FROM DATE ISSUED <br /> ICemplete le Tek&its) <br /> APPLICATION IB NFRE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PEIOAIT TO ComvTRIFCT AND/OR INSTALL THE WOW DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115`.3'AND THE STANDARDS OF SAN JOAOUIN cOUNTY PUBLIC HEALTH SERVICES,ENVmO ENF}AL HEALTH MIRBION. <br /> JOB ADDREBSIOR APRIIs�[ 6q yY <br /> CT! F� PARCEL et2E/AR7! <br /> OWNFA'B NAMFCI O S'F'D V`L AbORFO$4� Ek t>pf a 5 V\ PRONE!_ <br /> CONTRACTDRIPQ 1L►� �' 0�'11B -�-+.'G Ox �' c ��77 o-•• yi <br /> AbORFe9 UC! i0fC In PHONE!!-GC�1}oW <br /> l <br /> 4a !•Der+. <br /> 'I AV1B CONTRACTOR. 1 S C��1 r e V' ADDREee LlLIC;�j!PHONE F <br /> TYPE OF MP-. ❑NEW WELL ❑REPLACEMENT WELL ❑momauppNowitts ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CRo Be.COHNEC REPAIR ❑VAPOR EXTRACTION WELL E J <br /> RYTE OF PXMIh <br /> 13m—13R—k ".1" bEPtH PUMP BET FT. FIRST ER LEVEL O <br /> 1:3OUT.OF.SERVICF WFlI. ❑GEOPHYSICAL WELL! SOI!BOIVNb e <br /> ©OESTRUCTIoN; <br /> INTENRU! Ui TYPE OF WELL GONs RUCitOM BPECIFICA ION A <br /> ❑INHlBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO b <br /> ❑boMEBTIOmRIVATT ❑ORAVEL PACK7BIlE TYPE OF CASINOfBTEEUPVC CIA.OF WELL CASINO O <br /> ❑PUBLICAAUNICI'AL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑MMATtONUAG ❑OTHER GROUT SEAL INBTALIED BY OAOUT BRAND NAME E <br /> ❑MONITORING OROUT BEAL PUMPED:❑Y. He CONCRETE PEDESTAL BV bRB_LER:❑Yw ❑Na S <br /> APPROX,PEPTH LOCKING CHESTER I OXISTOVE PTE ` S <br /> PROPOSED CONSTRUCTIONMAILUNG METHOO:MUD VOTARY AIR FIOTARY AUOEA CABLE OTHER 154to p O6P.... <br /> I HE9EBV CERTIFY THAT 1 HAVE PREPARED TWO APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY OFIDINANCEB,STATE LAWS,AND RULES AND <br /> RFOVLATIONG OF THE SAN JOAOIJM COUNTY. HOME OWNER OA LICENSED AOENT'S BIONATURE CERTFF ES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> 1 THIS PERMIT IS IBBUEO,I SNAIL NOT EMPLOY PERSONS SUMACt TO WORKMAN-111 COMPINOATION LAWS OF CALWORNIA,•CONTRACTOR'S HIRING DR IRP"ONTRACTINO SIGNATURE CERTIFIES <br /> TIN FOLLOWING: -1 CFmIFV THAT IN TINE PERFORMANCE OF THE Wo1K Fon WHICH THIS PERMIT IS 18 UFD,I SHALL EMPLOY FfABONB SUBJECT TO 7VORIOIIAN's COMPINIATION LAWS OF <br /> CAUFOAMA.' TAP RIC ANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REOUREb INBPFCTIONS T 1"4141110410123CA�OUTIlE{rp�F1AWIN0 AT LOWER AREA PROVIDED. <br /> b,r• <br /> PLOT PIAN 10—1.9.0.1 Sn.I• 'to <br /> T. NAMES OF STREET q DS NEAREST To OR OOVNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIVOSAL SYSTEM OR PROPOSED <br /> R.OUTLINE OFT P/i0 ,GIVIAR DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS, <br /> 9. IMMFNGFONED OUTUNF.S AND LOCATION OF ALL FXIBFING AND PROPOSED E.LOCATION OF WELLS WITHIN RAORIS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUREB,INCLUDING COVERED AREAE SUCH <br /> AS PATIOS.DRIVEWAYS,ANO WALKS. ON THE PRDPER7Y OR AOJOIMNG PROPERTY. <br /> ..... :-.. .I. ... <br /> OWAA?MEIIT INS ONLY <br /> MPB.elIM Ae••pled eY D.I. / ' Y A.r <br /> Olein In,peatlen BY b•I• P—P I—i—d—B D t. <br /> pwl,tallsn 1.wpwelen ST 6.I. ' <br /> C•mmwNr <br /> A...-TIN.ONLY: MD/ FPC/ <br /> FE COOEB FEE INFO AMOUNT REMITTED CHECKlfCASH RECEIVED BY I ATE PERMITIBERVICE REGUEBT NUMBER INVOtC6 <br /> 350 1463rD ra l Grp �lOgra�- <br />