Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)460-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompletE In TripIkatE) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,,CHAPTER 9-1115.3 AND <br /> THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE88IOR,A�P,N./J//y�l2��//�J�X// �I (,"'6�0'`�� E�+'/'7C CITY [.Del PARCEL 8IZEMPN/ <br /> OWNER'S NAME�7 KC oe/„C"r'*-'+� L/_7/m((//JN ADDRESS� �I J} 7A�,L�L��✓G�-I-Q&Inlh C/7PNONE 131y�G�-.� <br /> CONTRACTOR�,(��nC7/A��I D✓T Mai ADDRESS Po Io i7V� Roo�yl�UC, gloo39FHONE.M'/3ol) <br /> SUS CONTRACTOR ADDRESS IJCI PHONE I <br /> TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> ❑New❑Fl p.lt H.P._ DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> / ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> DESTRUCTION: �IC-S T C�OI.� .T�rI Ci/ ) <br /> At <br /> ✓✓✓INTENDED USE TYPE O ONSTRUCTIO W,€CIFICATIONS it <br /> ❑INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑DOMEBTK:IPIBVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEIJPVC DIA.OF WELL CASINO D <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUT BEAL PUMPED:❑Y. (IN. CONCRETE PEOE@TAL BY DRILLER:❑Ye. [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOXMTOVE RPE d <br /> PROPOSED CONSTRUCTIONIMLLING METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE@ AND <br /> REGULAT90NO OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENr'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK TOR WHICH <br /> THIS PERMIT 1@17610,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.-COMRACTOR'8 HIRING OR BU"ONTRACTING SIGNATURE CERTIr1ES <br /> THE FOLLOWING: '1 CERtIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I @HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALF FtNIA.' T // A//NffT MUST yl{ t1 M@ IN ADVANCE FOR ALL REOtIMED/NS/n►//1:C NO AT 120014064422.COMPLETE DRAWING AT LOWER Z. <br /> PROS /� <br /> X. �((,(,��(CI (// Title Y 67' <br /> / <br /> PLOT PLAN ID,—le Seal.)Sept. 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DIBPOM SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERLY. <br /> :fie' r <br /> ..: <br /> t.....:............ ....>......�..... ....}......�.... <br /> ,��G,(\/� DEPARTMENT USE ONLY <br /> APPp..tl—Aeeepted By v �” - — Det. A— <br /> O'.vt Impeetl-By De1e Pt p I-Pwtlen by Ow. <br /> D-t—tl—I—Peetl—By Oete <br /> CemmenU: <br /> ACCOUNTING ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER! INVOICE <br /> 3 0 0 b 2 a5 � DIS? <br />