Laserfiche WebLink
APPLICATION FOR:WEL.L/PUMP PERMI— <br /> SA�_.,)AQUIN COUNTY PUBLIC HEALTH SES ES <br /> ENVIRONMENTAL,HEALTH DIVISION <br /> 364 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (269)488-31420 <br /> NON-REFUNDABLE PERMIT EXPIRES IYEAR PROYA DATE ISSUED <br /> tcomptats lR Trifid sta► <br /> APPLICATION IS TIERS BY MAM TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBEb,1018 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY OEVELflPMQ(r TITLE,CHAPTER 9,1115.3 AND THE STANDARDS OF SAN:JOAOUIN COUNTY PUBLIC HEALTH BmRVICES,ENVIRONMENTAL HEALTH DRVISION, �y;�Q� <br /> JOB ADDRESSIORACNP CITY/[ rARCEtSITEtAPNOWC -0, I f <br /> OWNERW NAME ADDRESS y i� <br /> , FH4NE:f=--r <br /> _ra `' <br /> CONTRACTORf�tr�`yt�r1.� Ucr�Fttor�r 63'�`'7�7� <br /> SUB CONTRACTOR ADDRESS iucs ptf��.F <br /> Il.laa.elll.e 11.aaa.l �.a�allallr��IYIIIIIIIMInalalllaa llaaaaaa�am•lalI IYIIYIIII/UY.YaalYl�ln� moll I®la��lafi�.aal! <br /> TYPE-OF,WELLJPt7MPt ❑ NEW WELL E3.REPLACEMENT WELL CII MONITORING WELL 1 T OTHER <br /> ❑:INSTAL.LA"TMIN CI..:WELL SYSTEM FIEPAM LJ CROBS•CONNECT REPAIR C]VAPOR EXTRACTIONYML I'. <br /> J. <br /> �.. D'Nav 0 RePitt 111t. DEPTH pump SET-FT. FIRS?WAT.ER.", <br /> (TYPE OF PUMPI.. <br /> ,may I :OVf-0E-9EAVICE WELL © OmOPPYSRCAL WELL 11 TIG.:80M.801gN0 <br /> W DESTRUCTION! f <br /> NfENOED U6 TYPE.OF WELL �t';jIISTRIiC.T1ON.8PECNICltlTIONf ... Ak.. <br /> CI INDUSTRIAL, i«J oPEN BOTTOM DIA.OF WELL;EXCAVATION OIA.OF CONDUCTOR dA9fN0 D <br /> Q DOMESTICIPRNVATE 1IF.- p0A*..PACKfBRE: .. TYPE or cAo N micttJPVC. DIA.Or WELL.CASINO: <br /> 1©t PUBUCIMUNIGIPAL IJ LNBVEN. 00ro OF ORDUf SEAL SPECIFICATION IT.: <br /> w tRttIGATPONIAG CIOTNEIi .6h*fT IEAI,tWALLEDI-BAY.. �T---tL,II GROUT.BRAND.NAME .. .:.. r <br /> © MONITORING '.GRDUT smPUMPED.LIYe. 6J,Ne, CONI:RETE:PEDEBTAL_BY:DRILLEft:.©Y.. I_w :s <br /> APPROX.DEPTH LOCKING CHESTER SOXISTOVE MPE_ g. <br /> PROPOSIED COMTRUCTtONtM1LINO METHOD-. MUD ROTARY AMi ROTARY;,,,,-,_,,AUGER CABLE OTHER <br /> I NE"M9Y:CERTIFY THAT I HAVE PREPARED TMIS:APPLICATION AND THAT THE WORK WILL:BE DONE:IN ACCORDANCE.WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS Of THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING."I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR VMC14 <br /> TIGIS PERMIT IS ISSUED,t SHALLNOT EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENBATTON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SMATURE CERHFIEB <br /> :THE:FOLLOWING, *I.CERTIFY THAT IN.THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I t3HAU..EMPLOY PERSONS SUBJECT-TO:WORIOMAN'S COMPO1tATION LAWS.OF: <br /> CALIFORNIA,- TT APPLICANT MUS Clwf 24FHOURS W ADVANCE FOR ALIL REGU1RmD INUP POONS At t20l)4#4ti21. COMPLETE DRAWING ATLOWERAMA PROVIDED,. <br /> . <br /> Slomm X�i L• ^*'a•-, .. Tltl� J'.t /+ttY Oete "!°`C -....... <br /> PLOTPLANIDrwv to Santal:8aafa .to <br /> I. NAMES.OF STREETS OR ROAD$NEAf*BT TO OR BOUNDINO:THE PROPERTY. 4. LOCATION OP'HOUSE:BEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY;GIVING DIMENSIONS AND NORTH DIRECTION. EXPANBtON OC SEWAGE DISPOSAL SYSTEM& <br /> 3.DIMENSIONED OUTUHFS AND:LOCATION-OF:Alt EXISTING AND PROPOSED 6...LOCATION OFWELLSWITHIN RADIUS:OF ONE MUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> • <br /> r: <br /> i <br /> DEPARTMENI`:USE ONLY J_ ... <br /> ;ApOltatlon An.IIIWA r +•E'L'I' .Data ;I !IEJ ArY • <br /> Ototo Inope0anlBY .. -. .... ..... .. Data Pump.htapsetbn By Data- <br /> Dammallen pectlen By, +, Dots <br /> CemmelNis •e"*"'� '� U" <br /> `�(..• <br /> ACCOUNT INI�XiAYt: A/Ds FAC# ,,J��II�,.t.i(�':il.�i <br /> PE COOTA FEE INFO AMOUNT AVATTED CHECKd1CA$H RECEIVED BY DATE PERMIT11 EHVICE REOVEAT NUMBER INVOICE: <br /> Pub.Health Serv,-FAWO 173(1" <br />