Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMII <br /> SAN JOAQUIX COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON. CA 56201-388 <br /> (2091462-3420 <br /> RORI•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IMED <br /> Ompl.a it Tripkats) j <br /> APPW.ATION IS BY MADE TO THE BAN JOAQUIN COUNTY FOR A PEWHTT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS AP"JCATION 16 MADE IN CDMPUASKE WITH SAN <br /> JOAOkXN COUNTY DEVELDPIIENT TITLE.CHAPTER 9.11"1�A5.3 AND THE STANDAA,FOS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> OPT <br /> JOB ADSSIOR APNS m/ SL*-4 ln*e, I •IIS30 W. 07-MAC PARCEL OIZE/APN/r.wc, 4C4 <br /> OWNER'S NAME�✓`=/�C- �r�{Ar�a.'�7'yS ADDRESS V~1L91A 4P-01 ��2/- - PHONE 90 74-0yoy <br /> cDNrnAcroR/ ��L d. /QnQ791dei++ t�oG ,Z'NG _ADDRESS� Aby9A,i .rsR/.uuc{ �90DPrnNE, <br /> SUB CONTRACTOR_ �^ ADDRESS 4 PHONE <br /> TYPE OF wEU/PuMP Iy-] NEW WELL ❑ REPLACEMENT WELL. ❑ NONrroww win rr ❑OTHER I <br /> El !NISTALLATTON ❑ WELL SYSTFM REPAIR ❑ CROB"ONNECT REPAIR 13 VAPOR E)(TRACTTON WELL I J <br /> ❑Na ❑RoW.Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> TTYPE OF PUMPI <br /> ❑ OVT4F-SERVICE WELL 11OEOPHYi1C AL WELLi �801E BWWB, //*f- LI <br /> ❑OE8TTWCTION: <br /> INTENDED USE TYPE OF wv& CONSTFRImIGN A <br /> v <br /> ❑ NW IPIWAL ❑OPEN BOITOM DIA.OF WELL EXCAVATION. f/.57 DUL OF CONDUCTOR CASING D <br /> ❑ DOMESTICIPNVATE ❑GRAVEL PAUCMeE TYPE OF CASING/STM,PVC AWELL <br /> C DI -OF LL CASING D <br /> ❑ PUELCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 00d-L- SPECIFICATION R <br /> ❑ IFWIGATKXUAG ❑OTHER GROUT SEAL INSTALLED BY GFIOUT BRAND NAME djf-- <<FL- 6*1 <br /> ❑ MONrrCWNO GROUT REAL PUMPED: [3 Y. ON. CONCRETEpEDE6TALwYDNILLFR;❑Yw ON. •�f%,e <br /> APPROX.091TH 20 ^YO oars _ LOCKWO CHESTER BOXISTOVE PIK 5 ^• <br /> PROPOSED FDNSTRUCTIONIDRIWNO MQMOD: MUD RO'TAR'Y AIR ROTARY AUGER CABLE OTHER t <br /> W <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPAAED THIS APPLICATION Ar/D THAT THE WORK WILL SE DONE IN ACCORDANCE WITH,SNI JOAQUIN COUNTY OfIDWANCES,STATE LAWS,AND RULES AND Q <br /> RMULATIONB OF THE SAN JOAQUIN COUNTY. HOME OWNER LM LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLI 002119):'1 CERTIFY THAT IN THE PERF13 WANCE OF THE WORK POR WHICH <br /> THIS PEFMrT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOIBGNAN'E COMPEMSATION LAWS OF CALIFORNIA.' CONTRACTOR'S WANG OR 8UB•CONTRACTNG SMATURE CERTFIES <br /> THE FOLLOVWJG: 'I THAT N THE PERFO NCE OF THE WON(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAWS COSSPEN&ATION LAWS OF <br /> CAUFORHLOL' ANY MUST CALL M ADVANCE FOR ALL REOUNIW NOWTIOORS/A�T�T30M 446.,64=. COMPLETE ORAWNG AT LOWER AREA PROVDED. <br /> Bigr dX _ <br /> 1 <br /> 1 Nv to Silly el>II4 '[ <br /> RILINE <br /> BB f} N O BOUNDING THE PROPMY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PfIDPOBED <br /> O THE PROPERTY.GIVINS DaWM91 ION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS_ <br /> 3• POSED 6. LOCATION OF WELLS WITHM PAPM$OF ONE HUNDRED FIFTY FT. <br /> H A8 YS, <br /> AND WALKS. ON THE PROPERTY OR AQJONING PROPUn-Y_ <br /> L. <br /> v�ork: <br /> ell <br /> r _. . <br /> :. <br /> _.b:...; �-�vtirnr�:.. : l He _ <br /> alai p����+on• <br /> .. .......:....,: ........ .. .. <br /> . :... <br /> ........ ...:.... <br /> ..... .a.. ...�........ ...:... .a.. ..:.. ..b.. ........ <br /> : <br /> c <br /> i <br /> • <br /> v. <br /> r <br /> 8 - <br /> Ir <br /> : <br /> /. <br /> I <br /> . <br /> Ti <br /> q <br /> :.. ..:.... : ... : .... ... ........ .. <br /> . ..< . .. .. .. °. ..:.. ..y... . . <br /> y. ... <br /> : <br /> .. '. PAY <br /> � . ..:.............:.. RENT.,. W. <br /> :.. <br /> t� <br /> ....... ........ ... ... ... . ... . <br /> .,R ,f e•.. <br /> , <br /> .. . - :� ': �.:. . .SEP <br /> OWPA ANT UNE ONLY ENV HEALTH SERV C c <br /> APFNwtbrl Aaapud Br * M Dom. f3 A L HEAL T(#� <br /> 6—d I[[y.aHwl By MI4 <br /> Pump hrpS4tlen by Dob <br />