Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M Trlplkmtsl <br /> APPLICATION 19 UFFIF BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDJOR INSTALL THE WOR(DESCRIREO,THIS APPLICATION IS MADE IN COMPLIANCE WrTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.33�A�ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRFS9/OR A�P(N/ 701 i �t�L- Clad r11 o r IOW G,\j CI-T/Y S j b(FJF��O� `�j L 1�PARCEL SIZEJAPNR <br /> OWNER'S NAME Kk9l ICA oo� OT�t�►'taP% A... (01 E- C641''r✓ WQy, / IF.` PHONE# 467-036 ` <br /> CONTRACTOR k ran C`(A 6-o �N N 1YLh M�d1 r�i� -ADORE88406� -w11f0/1 Lich 150)'##1 7 PHONE 146 7- 100 <br /> SUB CONTRACTOR ADDRE SB UC/ PHONE 1 <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL lAl MONITORING WELL/� 3 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS8LONNECT REPAIR ❑ VAPOR EXTRACTION WELL P J <br /> ❑New❑Rwak H.P. DEPTH PUMP SET R. FIRST WATER LEVEL O <br /> IT YPE OF PUMPI <br /> ❑ OVT-OF.SERVICE WELL ❑ GEOPHYSICAL WELL Jr ❑ BOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A DIA.OF CONDUCTOR CASINO n <br /> ❑ DOMESTIC/PRIVATE ®GRAVEL PACK/SIZE 0 3 TYPE OF CA91N0/BTEEUPVC VVIL DIA.OF WELL CASINO �/�,/ O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL 3 7 SPECIFICATION E. 40 q <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME ,OY IO 11 F <br /> I$MONITORING /h GROUT SEAL PUMPED: 0 Yr ❑No CONCRETE PEDESTAL BY DRILLER:11Y— [A Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE 5 <br /> PROPOSED CONSTRUCTION/DIILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 0 HMNY CERTIFY THAT 1 HAVE PREPARED THIS APPLJCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,18NALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFONMRA.- CONTRACTOR'S HIRING OR BU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORMA.' THE APPLICANTMUST C LL 24 IbUK9 1N ADVANCE FOR ALL REGUMREU INSP[CT/ONS AT 12001408-24". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> X )"�11 .� Tw. spit T <br /> 6{ r 5 D.I. <br /> ROT RAN PR9Jtew to 8eMe1 BoNe 'to <br /> NAMES OF 8TREETS OR ROADS NEAREST TO OR BOUNI.THE OPERrY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUTLINE OF THE PRDP'ITrY,GIVING DM FNBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> :I, DIMENSIONED OUTUNFS AND LOCATION OF ALL FX19TWO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS- ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L <br /> /7 DEPARTMENT USE ONLY <br /> Applbetlen A—.pted BY ' !/ •^�/ D.I. J C M.P V 7 <br /> d W— <br /> n."Ir»p-4—BY D.te Ptmp IMpeetlen BY De1e <br /> DMbllEllen IMpeetbn SY Det. <br /> C emmbMe• <br /> ACCOUNTINO ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DATE ►6MMT/8EAVICE REQUEST NUMBER INVOICE <br /> q 9 ' - — (coo <br /> Pub Heatth Serv.-EnvirO 173(1/97) <br />