|
APPLICATION FOR WELLIPUMP PERMIT OG�6zL/)9
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMEf�I
<br />ENVIRONMENTAL HEALTH DIVISION RECEIV
<br />P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388
<br />(209) 488-3420 F E 8 !�
<br />SAN ,1,,, ;
<br />NON-REFUNDABLE PERM PINES 1 YEAl FROM DATE ISSUED PL)BLIC
<br />ENVIRONMEfv1A r;((,{{
<br />APPLICATION IE HERE BY MADE TO THE BAN JOAOUI COUNTY FOR A PERMIT To CONSTRUCT ANDA. INSTALL THE WORK OESCRISED, TMS APPLICATION Ie MADE M ZbRIbVANCE WTO4AN
<br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9' 1116.3 AND THE l!STANDARDS OF BAN, JOAQUIN CO/ILINTY PUBLIC HEALTH SERVICES, ENVMONMEMAL HEALTH OMSION.
<br />JOB ADORESS/OR APNI - 7 - ' `� O� WV L�f di? s PARCEL S=AP*H
<br />OWNER'S NAME ) i C
<br />A
<br />D
<br />O
<br />R
<br />f
<br />S
<br />APPROX. DETTN LOCKNO CHESTER BOX/STOVE PRPP s.
<br />PROPOSED CONSfl1UCTTONIDIfLLNO METHOD: MUD ROTARY AIR ROTARY AUOE11__,,25_ CABLE OTHER
<br />I HPEBY CERTIFY THAT 1 HAVE PREPARED THIB APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES. STATE LAWS, AND RULES AND
<br />REOULATlON6 Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br />THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSON$ SUBJECT TO WORKMAN'S COMP9/6ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIR04 OR $US CONTTUCTINO BMATUIIE CERTIFIES
<br />THE FOLLOWINO: ' 1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH TINS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SU6UECT TO W01110AAN'S COMPS"ATION LAWS OF
<br />CALIFORNIA- APPLICANT APrPLICANT MUST CILL 24 HOURS IN ADVANCE FOR ALL RE TIO AT 1200) 466.3423. COMPLETE DRAWNO AT LOWER AREA PROVIDED. N`
<br />SlSrrd X l'. !, _ TNN Dw•f
<br />` ROT PLAN (Orwa to teWl S..w ' to
<br />1. NAMES OF STREET�OR ROAD$ NEAREST TO OR BO NDNO THE P'MPFRTY. NI. LOCATION OF ROUSE SEWAGE 04SPOM SYSTEM OR PPOPOOM
<br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSION$ ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. (�
<br />T. DIMENSIONED OUTLNF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOREO FIFTY FT.
<br />STRUCTURES, INCLUOINO COVERED AREAS SUCH A4 PATIOS, DRIVEWAYS, AND WALLS. ON THE PROPERTY OR ADJONINO PROPERTY,
<br />Si'lE i'.J�A ON
<br />�.. .. .. .. . ..
<br />-
<br />.T .. .
<br />..........i............
<br />.. .
<br />.... ...},-- ...4...
<br />AP�pstlen Aao.pc.a eY
<br />19 L
<br />ADORES$ (&)j wc i ►1'10\?�
<br />L1IN4 FFIONE.
<br />CONTRACTOR- 6,"-
<br />Grwt hupamlon By -
<br />r 0
<br />ADoRESSj4-19)3sc- 7
<br />1> v
<br />Lica PHONE « ) G�.
<br />SUBCONTRACTOR
<br />L
<br />�f
<br />, 1 1 ,
<br />ADDRESS /
<br />s� LlG s s T 7 % q /
<br />1 �
<br />/•-
<br />PHONE
<br />TYPE OF WELLPUMP•.
<br />❑ NEW WELL
<br />❑ FIREPLACEMENT WELL.
<br />1� MONIT0R;NG WELL / 1`� 11 1
<br />13 OTHER
<br />❑ INSTALLATION
<br />❑ BYSTEM REPAM
<br />❑ CMS"ONNECT REAM
<br />❑ VAPOR EXTRACTION WELL /
<br />ACCOUNTINO ONLY:
<br />D NwN ❑ PYpw,
<br />M.P.
<br />DEPTH PUMP BET FT.
<br />RW WATER LEVEL
<br />J
<br />0
<br />(TYPE Of PUMP)
<br />t1EST N
<br />❑ -0F SERVICE WEll
<br />❑ GEOPHYSICAL WELL I
<br />❑
<br />bIL BORING
<br />;
<br />❑ DESTRUCTION:
<br />A
<br />D
<br />O
<br />R
<br />f
<br />S
<br />APPROX. DETTN LOCKNO CHESTER BOX/STOVE PRPP s.
<br />PROPOSED CONSfl1UCTTONIDIfLLNO METHOD: MUD ROTARY AIR ROTARY AUOE11__,,25_ CABLE OTHER
<br />I HPEBY CERTIFY THAT 1 HAVE PREPARED THIB APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES. STATE LAWS, AND RULES AND
<br />REOULATlON6 Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br />THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSON$ SUBJECT TO WORKMAN'S COMP9/6ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIR04 OR $US CONTTUCTINO BMATUIIE CERTIFIES
<br />THE FOLLOWINO: ' 1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH TINS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SU6UECT TO W01110AAN'S COMPS"ATION LAWS OF
<br />CALIFORNIA- APPLICANT APrPLICANT MUST CILL 24 HOURS IN ADVANCE FOR ALL RE TIO AT 1200) 466.3423. COMPLETE DRAWNO AT LOWER AREA PROVIDED. N`
<br />SlSrrd X l'. !, _ TNN Dw•f
<br />` ROT PLAN (Orwa to teWl S..w ' to
<br />1. NAMES OF STREET�OR ROAD$ NEAREST TO OR BO NDNO THE P'MPFRTY. NI. LOCATION OF ROUSE SEWAGE 04SPOM SYSTEM OR PPOPOOM
<br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSION$ ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. (�
<br />T. DIMENSIONED OUTLNF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOREO FIFTY FT.
<br />STRUCTURES, INCLUOINO COVERED AREAS SUCH A4 PATIOS, DRIVEWAYS, AND WALLS. ON THE PROPERTY OR ADJONINO PROPERTY,
<br />Si'lE i'.J�A ON
<br />�.. .. .. .. . ..
<br />-
<br />.T .. .
<br />..........i............
<br />.. .
<br />.... ...},-- ...4...
<br />AP�pstlen Aao.pc.a eY
<br />DEPARTMENT USE ONLY
<br />Dao � � / w A,o. �!
<br />INTENDED WE
<br />❑ INDUSTRIAL
<br />❑ DOMESTTC/P19GRAVELVATE
<br />❑ PUBLIC/MUNICRPAL
<br />❑ IRRIGATION/AG
<br />(11 1.IONTTORONG
<br />„
<br />TYPf Of WELL
<br />❑ OPEN BOTTOM
<br />❑ GRAVEL PACK/BQE
<br />❑ DRIVEN
<br />❑ OTHER
<br />Grwt hupamlon By -
<br />CONSTRUCTION 4MIRCATIONS
<br />DIA. OF WELL EXCAVATION ,r
<br />TYPE Of CA61NO/STEEL/WC r /
<br />DEPTH OF GROUT SEAL L- r
<br />GROUT SEAL wvALLED BY_/-, j �,".
<br />GROUT SEAL PUMPED: ❑ N•
<br />DIA. Of CONDUCTOR CASINO —
<br />p1A. OF WELL CASINO
<br />g4C1FICATION
<br />GROUT BRAND NAME
<br />CONCRETE PEDESTAL BY DRILLER: ❑ Y. ON.
<br />A
<br />D
<br />O
<br />R
<br />f
<br />S
<br />APPROX. DETTN LOCKNO CHESTER BOX/STOVE PRPP s.
<br />PROPOSED CONSfl1UCTTONIDIfLLNO METHOD: MUD ROTARY AIR ROTARY AUOE11__,,25_ CABLE OTHER
<br />I HPEBY CERTIFY THAT 1 HAVE PREPARED THIB APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES. STATE LAWS, AND RULES AND
<br />REOULATlON6 Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br />THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSON$ SUBJECT TO WORKMAN'S COMP9/6ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIR04 OR $US CONTTUCTINO BMATUIIE CERTIFIES
<br />THE FOLLOWINO: ' 1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH TINS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SU6UECT TO W01110AAN'S COMPS"ATION LAWS OF
<br />CALIFORNIA- APPLICANT APrPLICANT MUST CILL 24 HOURS IN ADVANCE FOR ALL RE TIO AT 1200) 466.3423. COMPLETE DRAWNO AT LOWER AREA PROVIDED. N`
<br />SlSrrd X l'. !, _ TNN Dw•f
<br />` ROT PLAN (Orwa to teWl S..w ' to
<br />1. NAMES OF STREET�OR ROAD$ NEAREST TO OR BO NDNO THE P'MPFRTY. NI. LOCATION OF ROUSE SEWAGE 04SPOM SYSTEM OR PPOPOOM
<br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSION$ ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. (�
<br />T. DIMENSIONED OUTLNF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOREO FIFTY FT.
<br />STRUCTURES, INCLUOINO COVERED AREAS SUCH A4 PATIOS, DRIVEWAYS, AND WALLS. ON THE PROPERTY OR ADJONINO PROPERTY,
<br />Si'lE i'.J�A ON
<br />�.. .. .. .. . ..
<br />-
<br />.T .. .
<br />..........i............
<br />.. .
<br />.... ...},-- ...4...
<br />AP�pstlen Aao.pc.a eY
<br />DEPARTMENT USE ONLY
<br />Dao � � / w A,o. �!
<br />Grwt hupamlon By -
<br />Dai
<br />Ptmp IrrPwrtbn Sy
<br />Drnuadon kryptlen BY
<br />Dae
<br />ACCOUNTINO ONLY:
<br />AID#
<br />FACE
<br />IL PE —ca OEJ PEE INFO
<br />AMOUNT RONITTED CHECK//CASH
<br />RECEIVED SY DATE
<br />t1EST N
<br />INVOICE
<br />d Ib:01 96/10/20 WOaA
<br />
|