Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT DaS Soy <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> 101-NUUNDADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1c.mpiEb M Tripil"tel <br /> APPLN;A!ION le ERRE BY MADE TO TILE RAN JOAOMN COUNTY FOR A PFRMTT TO CONSTRUCT ANOMS INVALL THE WORK DESCRIBED.71118 APPLICATION IS MADE N COMFLIJ.NCE Wrll SAN <br /> JOADU%N COUNT-Y VCMOFVAEENT TITLE.C" EA G 11.16.7'ASND THE EtANOA M OF RAN JOAOUH COUNTY PPUBBLLICC.HEALTH e_EnvicEB.ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADMITS$.EM APNI dlv� 1 ] 1�_�Q, i_CITv ��\L. `(,. L ►AKfAR.IZE1111�'HIRyCTy� <br /> OWFIER'e NAME 1�T� •V^�4�AOPE88 �l iL I�l l� UC/Lr(nWt�-V -- I�—E 5 <br /> co«rRAc,oR_U pC;F 9>�5\ r l i <br /> ADOFABR UC. ►HONE F <br /> TYI'E Of WELUPVEAp: D r:[lY WRl ❑WMACEASENT WELL ❑--.Mn..ELL I D OTHER <br /> 1 �.❑,(INSTAILATION ❑Wnk OSTEM RIPANI ElCAOSe-CONNECT REPAIR ❑VAPOR ERT MCTM.IN W'E ; J <br /> �-y{�,l l�~J ,6J NFn L114oF1r H t• ot"m PUMP-ktA T. FMOT WATER <br /> O YPf OF RNAPI <br /> �y t ❑OUT OF RFRVICE WELL ❑OEo-1 R'c- WELL I ❑ ROIL IIOMN:1 I, `` <br /> �e77AG,N,.I• .�v�k�4 QID C, �1P,Lx7 �`/� 11� C-AAk;:, 1].�- vr+ <br /> INTEMDm U.l Y OF WFI.I CONSTRUCTION♦ A IONS A <br /> CI TNnVSTMAL ❑OPEN%GIIOM DNA.OF WELL FXCAVATION ENA.OF CONDIICton LADING O� <br /> OOWIITICA'>RIVATE ❑GRAVEL PACK/PRE TYTT OF CAIIINOISTEELJPVC IRA,OF YYRL C.AMNTI_ O <br /> ❑PUIY,ICA MICPAL DOTEVEN DEPTH OF G Rm UT 8Fµ MiCIFICA71oN S <br /> ❑IRMOAIIONIAG ❑OTTIER OROUT 8EµINSTALLED SY JROUT mwm NAM[ f <br /> D MONITORING OROUT SEµPU1.NF0:DYE D W CONCRETE PEDESTAL BY DRILLER:❑Y- ❑Ne 3 /\/\/\����``` <br /> AFAIOK.of"H LOCKING CHESTFR SOXIEIOVE APE _ S <br /> P CM"O CONSTRUCTIONMAILUNG METHOD: MLA 110TAIIY AM IIOTAFIY AUGER CA8LE OCHER <br /> I IIE^EBY CERTIFY THAT 1ITAVF,MPAED THIS APFLICA,ION AAV THAT THE WDAK MALL 8E DONE IN ACCORDANCE VM TH SAN MAGIAN COUNTY ORDINANCES,STATF LAWS.A!A)MREe ANO <br /> ROUNATIONS OF THE SAN"A IN COUNTY.NOW OWNER OR`KINSEO AOFM'S BIONATURE CERTIFIES THE FCU. I'J :'1 CERTIFY THAT IN THE PIWORMANCE OF TILE WOK FOR YAM <br /> TNM FERAEIT M IRM/TO,1 SHALL NOT EMPLOY P91SON8 StFRACT TO WORKMAN'S COWO"SA—M IA—OF CALIFCF ,A.'COPTTRACTOR'B HANG OR MM{OMRACTINO WONATUIE CERTIFIF� <br /> 111E FOIL 1 CTTRIFY]fM�S CTALL Il HOWAIN AOVANCS FOIL ALL IFSOIIMED M S TEOMS AT e}MI ME-122.COMR[TX DIRA,"A AT LOW[FI AREA PNOVIMO"Tom UWS of <br /> CALIFOMR TI PPl1C 1U( �/f G <br /> TRI. SP1 1 <br /> PLOT HAM 10—w S.WI M.I. •to <br /> 1.NAME TRFRS O0.MADl1 NEA/1E8T 70 OR BOUHOSIO THE PIKH`Fj<TY. .. LOC ATgN OF HOUSE E[WAO[TNSPOsµEYBT(M OR pfpFOeED <br /> �.OVTU OF THE T'ROIER7Y,gVING OIMFNKONB AND NORTH LRRECTION. SI <br /> EXPANON OF SEWAGE 04TIMSµSYSTEMS. <br /> n.OHAFI~140 OUTLETS ANO LOCATION OF ALL ERISTO TNO AN�F�FaTO�P�OSED S.LOCATION OF MALS MITTIItT1 RADgE OF ONE HUNTOWD FNTY IT <br /> STRUCIUREE.INCLUOINO COVEJEO AJIEAS SUCH AS PATIOS,OIBYEWAY8,ANO WALKS. ON THE r"OFffffY OR ADJOINING PROPEN7Y. <br /> �--=, ;lip. <br /> ..... .:. : ...:. <br /> . A? <br /> _. . . . . ..... PAYMENT'- <br /> f3ECE�g� <br /> I r . <br /> -Na 19 <br /> Ad <br /> --_� <br /> p`;SAN <br /> UBUC HEALTH SE SEFM CES , <br /> EpWIpON[AENTRI.HEALTH p1YISION <br /> (/ OWARTMENT UBe ONLY <br /> App•,• A..wt.d 8Y \ - n O.e.�/) <br /> nr«A Ir.�A.n eY Dkl <br /> D..IP�INr.1r.P.p1I«I BY- <br /> C-- <br /> COVER <br /> YCF•r..n«.F:COVER FEE INFO AMOUNT RDAFTMD HEC R:ASN R[C6VFD■Y DATE PEMSTISEP.11E R[OUSST NUMBER ICE <br /> Z lI �Fai1P9 <br /> Put.Health Sere.-Envtto 173(1197) <br />