Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> %..e SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIW <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 9EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> 88, 904 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CGNpMto In Trblk{tel <br /> APKgATgN IS <br /> IIEPE BY MAGE i0 THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANI INSTALL THE WOR(DESCRIBED.TIPS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAGUIN COUNTY DEVELOPMENT TELE.CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIPONPARCEL SIZEIAPNENTAL HEALTH I/�✓-O^-/� <br /> r�� +IPL, Flub Bud Curt 57odcrQa��p/L Z11 �F <br /> JOB ADDRESSOR APNE 2,t ]E o, BOX O`_I ,V t� PHONE I l �3 S-J�a ? <br /> /L .t/ o I I 171MA qct CQ , ADGnf{e <br /> OWNER'S NAME��L f-(_/✓yJ-F�� <br /> 6►1Vi' ys FG^� ADDRESS Pfa8Vxa � •uJ�LLL�E <br /> COMPACTOR Q(� ` 0 D <br /> BUB COMMCTOP��-ylS/f�I MDREBBy�!sV�R� OY�-IIVZ DCI PHONE N/V— <br /> V� 13OTHER <br /> TYPE OF WELLIPUMP: ❑ NEW WELL E] REPLACEMENT WELL ❑ M,NITGRIND WELL I ❑ VAPOR EXTRACTION WELL A J <br /> ❑ INSTALLATION [I WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAID <br /> ❑N.w❑11en•Ir N.P. <br /> DEPEH A1MP SET FT. FIRST WATER LEVEL — O <br /> GYM OF MMPI WELL N <br /> GEOAIVSICAOd BOIL BORING <br /> ❑ OUT-0FSERVICE WELL ❑ I. <br /> ❑DEST.UCTIOW <br /> INTENDED USE TYPE OF W CONITRUCTIOM SPECIFICATION{ ^ <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASINO D <br /> ❑ DOMESTICITONATE ❑GRAVEL PACKIe1ZE TYPE OF CASINOIBTEEVPVC DIA.OF WELL CASINO D <br /> ❑ FUBLICMUNICIPAL ❑DmvrN DEPTH OF SWEET SEAL SPECIFICATION R <br /> R❑.t IRMGATIONIAG 13 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> IP MONUOIVNG onOUT DEAL PUMKO: 13 Y. ❑Ne CONCRETE PEDESTAL BY ORILLER:❑Yr ❑Ne 5 <br /> APMO[.DEPTH LOCKING CHESTER ROWSTOVE PIPE 5 <br /> MOPOIFD CONSTRUCTIONIUWLUNO METEIOO: MILD ROTARY AIR ROTARY AUGER CABLE OTHER c P r <br /> I HEREBY CERTIFY TIIAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL BE GONE IN ACCORDANCE MTN BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS Of THE BAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOIEL FOR WHICH <br /> THIN PERMIT IS ISSUED.I SHALL NOT EMPLOY MINIONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES <br /> THE fOLLOMNO. 'j CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMKOY PERSONS SUBJECT TO WORKMAN'S COMPFNIATION LAWS OF <br /> CA ORNA' PUCMIT MINT CA 24�MTNANCE FOR ALL REOUMEII INIIIMT1KINS AT VKH114NNV,*HHL COMR.ETE DRAWING AT LOWER AREA PROVIDED. <br /> X TIII. (>"lYN toil ' L �-� D.E. 7 <br /> not KAR MI.w ro S.H.I e..W 'ro <br /> 1. NAMES OF STREET ROADS NEARBY TO OR BOUNDING THE PRDPKRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On rl UMMD <br /> 2. OUTLINE OF THE KRTY,GIVING DMFNSION9 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPDBA,SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND FMIMSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FlrrY ET. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROKRTY OR ADJOINING PIgKRTY. <br /> yTe i�� A-tfiu-cl�l <br /> DEPARTMENT USE ONLY <br /> APPIIPHIen AmePlpl By � {/\ <br /> _ Dera `LJ Mw <br /> fireul 1�.#..pNF BN D.la Pump lnvp e,i.n By <br /> O.E. <br /> U+rrmBen Imnmrlon By <br /> D.111 <br /> ce,nma <br /> ACCOUNTING ONLY: NON FAC# <br /> PE COOEI FEE INFO AMOUNT REMITTED CHECK#LCMH RECEIVES{Y DATE <br /> 95D IEIWIIT/IFAVICE REQUEST NUNDBI INVOICE <br /> 0. 61 13 1 <br /> Pub.HeaRh SON.-Enviro.173(3/96) <br />