Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVRI/a <br /> ENVIRONMENTAL HEALTH DIVISION T �J <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201 ffAY 3 L <br /> (209) 4883420 1995 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSU P�1�/�(�] <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL STALL THE WOpf OE8CRIBEO.TAISY'i(PFI(C <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTTALIHEALTH DIVISION.ONCE WHIN SAN <br /> JOB ADORESSIOR•AAM, 7-4'5/ -5'041W 4/2po;Z-r ,'4Z Cm STOCKTON <br /> OWNER'SNAME UGAlIV90 $AK/NG- GQ• � PARCELSIZE/APJf � 7r/�C21�S <br /> T <br /> ADDRESS 6'=,4VFc 5ACRAMrr_i`iM 95',11 7M. 9/b 9ri(e-3$63 <br /> coNrRAcroRU/&ST NAZnIgT L7l?ILlIN4 Co(C(> O Cn2Ct+VA //Lg7q <br /> ADDRESS LICK[{7��>4" �bNEI �3G''7L7� <br /> SUBCONTRACTOR <br /> ``' ADDRESS LIC, PHONE, <br /> TYPE OF WELLIPUMP' I�NEW WELL ❑ REPLACEMENT WELL ❑ MONMORING WELL, A n�c <br /> (L,J�-INSTALLATION ❑WELL SYSTEM REPAIR A-THEFS SPAtz& (A11LL.LS <br /> ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑P.ep.lr H.P. DEPTH PUMP SET T. <br /> (TYPE OF WRAP) _FFIRST WATER LEVEL 0 D <br /> DESTRUCTION: E3OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL, ❑ WIL BORING <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION HPECIFICgTIONB <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /0 DIA. <br /> DIA.OF CONDUCTOR CASING 1'11A A <br /> ❑ DOMESTICNIUVATE ❑ VE <br /> GRAL PACK/SIZE TYPE OF CASINOISTEELNVC SCH -T'v P(/C- DIA. 7 T/ D <br /> ❑ WSUCIMUNICIPAL ❑ D <br /> DRIVEN �pZ F OF CASINO_ G D <br /> EPTH OF GgOUT SEAL �' SPECIFICATION <br /> ❑ IRRIGATIONIAG ❑ GROUT <br /> OTHER SEAL INSTALLED B((IYCON7'2I? A <br /> 4 g GROUT BRAND NAME TYPE _ <br /> 11MMONITORINGRINO L1j.-.� <br /> GROUT SEAL PUMPED:Ar Y. [IN. CONCRETE PEDESTAL BY DRILLER Y. o S <br /> AFRIOX.DEFTm —07*L- '(71c.pT{F ..,js <br /> LOCKING CHESTER BOX/STOVE PPE <br /> Y-4; S <br /> PROPOSED CONBTRUCTIONNPoWNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCEWNN BAN JOgpUIN COUNTY ORDINANCES,STATE LAWS,AND PULLS AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FoLL WINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> PERMIT flMIS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORItMAN'i COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN{ATION LAWS OF <br /> CALIFORNIA.- THE APPIICANT MUST C 34 IN ADVANCE FOR GUIRED IM TONS AT(308)SSSJi38. COMPETE DRAWING AT LOWER AREA FMMOED. <br /> rul"4 N2MM/rX (✓/Jyp,E_�- I J� <br /> Ill �• Tltle /4LO'J'CC�/ /'TQI^'P�/y(/`_ Det. 0.30 95 <br /> m_. <br /> l <br /> qw w«qa a. <br /> »'w IunmA-�+m cnw <br /> I Rwn«.»ao <br /> Id2 xcl l [O>RM 1M�Q� <br /> nvrwr <br /> v_,9 -w.rospmts <br /> Ov-i •m-° I <br /> (a51ro) <br /> (opsiw) <br /> LEGEND <br /> ---___ mlcx RPllwC �Tfj <br /> EI <br /> PTA(M PiE NgI1Np <br /> N <br /> _ q»a <br /> Y Proposed Well and Piping Lacoti.ns <br /> BURLINGTO <br /> ENVIRONMENTAL Sn..I 3 pI 6 <br /> v.•ne <br /> DEPARTMENTl <br /> USE ONLY I P S <br /> Applbnlen Aaroted BY Dae <br /> Grout ldoP ien BY D.teb/iihs Pump Inspection BY DW. <br /> Deodnxdlon Inpeatlon BY u Daa <br /> C....: <br /> ACCOUNTING ONLY: AID, FAC, <br /> RE GOOFS FFE INFO i AMOUNT REMITTED I CHMUICASN j RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3S � 3a 3 <br />