Laserfiche WebLink
aoszl� � <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 368, 3D4 EAST WEBER AVENUE, STOCKTON, CA 9M1-488 <br />17091461-3420 <br />MOM REFUMOAN' PERFiIT EXPIRES f YEAR FROM DATE ISSUE <br />APPLICATION IS HERE BY MADE TO 7NE SAN JOAOUIN COUNTY FOR A PERMIT <br />f. <br />TO CONBTP�K:TAND ORREWSTAkL <br />TNF WORN DESCWSED, TIIIS APPLICATION I6 MADE II COMM. IANCF WITII SAN <br />JOAQUIN COUNTY DEVELOPMENT Tr1U F. CHAPTER 9-1115.3 AND 711E STANDAnD6 OF RAN JOAGUIN COLINIY PUBUIC IIEAL711 SERVICER, ENVIRONMENTAL <br />IIFALTN DIVISION. <br />JOT ADORESSIOR APNT G Q '^% (,� .il •L,� CIT- s r G x ro.L/ <br />OVJFIfR'B NAME,_` GN /j /S AC N (e o <br />np. <br />P,ARCfI SITEIAPNI_ <br />ATORFBS S.n A'N ( SZI L 77 �•+ <br />CONTRACTOR kj (I /-A CIG -!1ky, C� <br />i <br />-ONE 7 <br />AnbnE88 �.45'tt& /S <br />— V aT � int [7�L/! LICA S PHONE, <br />Rue CONTRACToR <br />S 7IC ti r(� 2/ <br />ADDRESS_ -r— <br />"I'T OF CASINGMTFFUrVt <br />_' <br />Lice PHONE F <br />TYPE OF WELIJRIMP• ❑ NfW WELL ❑ REP"CEMENT WFUL <br />❑ MDNIT-4 WELL F ❑ <br />j ❑ IlStNUTN)N ❑ WILE SYSTEM PEPAIn <br />S�FO�Q ❑Nw M. <br />OTNfER <br />❑ CMRS.CONNFCI REPAIR ❑ VAPo, E%TMC1'ION WFII! l <br />+n Np. S AL L7 <br />R)Y'PE�OF(l:PVMP1 /J� 1 1--� <br />��.Tc..E ri P'e 'C/l�� / F'►1� i'!k� Li oUP-DF.xERVICE WTI l <br />/ <br />DEPTH F\1Mn bE TFT, fSTeT WATER LEJEL��_ <br />❑ <br />F--� FF <br />LE DESTRUCTION - <br />OEOIYIV61C 41 WELL J ❑ ROP. BONNO It 1 <br />INTENDED USE <br />❑INOVBTPoAL <br />iYpFo WELA - <br />CONS rRI/C71oN SPEGFK:A TIORS <br />- <br />ME971CS'IBVATf <br />❑OPEN SOTTOM <br />❑ GRAVEL PACKISIZE <br />DIA, OF WELL FXCAVATION_ <br />DIA, OF CONbVCTOR CARING <br />PUBLICIA7UNICIPAL <br />Tryry <br />L..1 v"" <br />"I'T OF CASINGMTFFUrVt <br />_' <br />— dA., OF WELL CASINO <br />❑ IRRIOATIONEAG <br />❑ OT/1ER <br />DEPTII OF CDOUFFFAl <br />P/'ECIFICATKIN <br />El MOM 70RIN0 <br />GAOIii SEAL HF61 AFI FD SV <br />_` <br />GROUT BRAND NAME <br />APIYlO%. DEFTu <br />GROUT SEAL PUMPFO� 11 V- C1 N. <br />1E--�y <br />CONCRETE PEDESTAL RY DAILLER: ❑ L <br />Yr /N. <br />LOCKOIO CHFSTER BO%.'SFOVE PPE Prom -ED CONI TRUCTIONIMIJ(UNOMHOD; MVO /OTARY_ <br />3 <br />Alfl ROIARV AIIRER _ CABLE OTNEII <br />I HE RFBY CERT IFY MA71 IIAVE iREPAFED T/BB AFTLICATION AND TIIAi 7HF, VYIITK WILT SF fgNE IN ACCGgIIANCE WlTlf SAN JOAOUIN COUNTY ORDINANCES, BATE LA.W1, ANO RUlF6 ANO <br />REOULATNIT 1 OF THF BAN JOAOLMN NOT COUNTY, NOME OWNER OR LICFlVBFD ASEM'B RIONATUgE CERTIFIE6 ENE FOLLOWTN11; •1 CERTIFY THAT IN THE FFIB'ORMANCE OF THE WOW FOR WIRCII <br />THB PERMIT IB IBBII[D,1 MfA[L NOT EMPLOY FERRONB SUBJECT TO WORKMAR'■ COMPERSATION LAWS OF CALIFORNIA.* CONTRACTOR'S LBRINO OR OUB -CONTRACTING SIGNATURE CERTNIFe <br />TIE FOULOWINO: • 1 CERTRY THAT IN T11E PERFOIIMANCE OF THE WOF% FOR WHICH 7 HI8 PE11Mrr IB IBB VEA, f 1NAlL EMPLOY CALIFORNIA.' FII cAM MVFT CALL ZI HOlB14 IN ADV PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />ANOE FOR ALI, REGURTO ON TONS T 12051E IJdf], CO'A Lpt (DRAWING AT LOWER NEA AgNDED. <br />—� .a tlUs D.1• I( <br />I. NARES OF BT PLOT FLAN ID— la SnMM <br />STREETS OR ROADS NFARF11T TO OR ROUNDING THE TRMTRTY, <br />OVT4. LOCATION OF 110UBE SEWAGE DISPOSAL BVBT[M OR PMM6E0 <br />2<. NNE DF TIE PROPERTY, UFV*,o DIMENSIONS AND NORTH DIRECTION, <br />T- DIMENSIONED OUTLIN:1 AND LOCATION OF ALL EXISTMO AND PROPOBFD EXPANSION OF SEWAGE d1P01AL SYBTEMF- <br />"FB)CTUIIER, INCLUDING COVERED AREAS Rtw. AA eAnn• r.... , -. _ B. LOCATION OF WELLS WITHIN RADIUS OF ONF 111NInnn1 rlrry r. <br />bEPMTMFNT USE ONLY <br />AM1100101 A-mtM <br />Grout ImppOtO— Ry <br />OMtncUo.. I�nny.lie� Ey` <br />-- DFre / z 613'1 <br />ACCOVNTING JNLY; AID, <br />PE CODES <br />FEE INFO <br />AMOUNT RWITTED TIE FlCALII <br />RECEVFO BY <br />BATE P 6WIITISFRVICE IUiOUEaT NURSER <br />INVOICE <br />c�5 0 <br />_ <br />0 �oov� <br />y6 v a i <br />0 j <br />Pub. Health Sere - EnVira. 173 (3196) <br />wv� <br />