Laserfiche WebLink
�r APPLICATION FOR WELLIPOMP PERMIT <br /> �� <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> U� <br /> a� 1 ENVIRONMENTAL HEALTH DIVISION !;r i <br /> -7 p P.O.EJw�(988,904 EAST WEBER AVENUE,STOCKmN,CA IkS201388,.a <br /> I c� 167 s (209)468.34-20 1. <br /> �. - SII. COPY <br /> EFUDaABLE PERMIT EXPIRfB I YEAR FROM DATE ISSUED + <br /> �/l((JJLL IComplElE IR YltpRnuf <br /> A CATION IB HERE T MADE To THE BAN JOAOCOUNTY rOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DFBCMRED,TtbB AMICATION TB MADE IN COMT'LIANCE WITH BAN <br /> y I JOAZOWN COUNTY DEVEIJM LOPMFNT TTfLE,CHAPTER 9-T 116.3 ANO THE STANOARbR Or BAH JOAOUIN COUNTY PUBLX`HFALTH BFRVICER,ENVNIONMFNTAL HEALTH DMSgN. <br /> JON AD R ESSIOR APHN 2 Q-7»-� `0 CITY 46-5 f - f-F S t <br /> PARC�L BgEfAMI Q <br /> -\ OWNER'@ NAME C Q� <br /> CONTRACTOR IRI •5 S +P+�S ADORFgR Al >S oS 't Uc/ ft/jq PHONE <br /> OUR CONTRACTOR AOORESM LIC/ THIONE/ <br /> TYPE OF WELEJPUAIPI ❑NEW WELL ❑RfPJACEMENT WELL ❑MONITORING YVELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL RYRTEM REPAIR ❑CROSR"CONNECT AFFAIR ©VAMR EXTRACTION WELL I -) <br /> ITYHE OF PUMP) <br /> 11New❑Rm.1, H.P- DEPTH PIMP RET Ft. FIRST WATER LEVEL o <br /> ❑OUt.OK-SER E VaELL Cl GEOPHYSICAL WELL/ ❑ 001L ROPING R <br /> Ip OEBTRucitom A' <br /> r O <br /> INTENDED i6 TYPE OF W CONiTR ON BPECIRC OMS A <br /> la INDUSTRIAL ❑OPEN BOTTOM DIA.oP WELL EXCAVATION btA.GF CONDUCTOR CASING V <br /> ❑DOMEBTICIPAIVATE ❑GRAVEL PACEISRE TYTE OF CARINOIBTEFI lPVC VIA.OF WELL CARMO n <br /> ❑PUSLRCIMUMCIPAL ❑OrMN DEPTH OF TLROUT REAL BPE'Ct"CATION A <br /> ❑MMOATIONIAG ❑OTHER OROUT SEAL METALLED Ry_ GROUT BRAND HAMS E <br /> ❑MONRORINO OROUT REAL M MTEb:❑Yw ❑Ne CONCAETE PEDESTAL BYDNILFR:❑Y. ❑Nw S . <br /> APPROX.OE►TH LadONG CHERTER BOXBrOVr PI14 5 <br /> PROPOIED CORRTTIMrIONIbpLLNIO METHOD: MUD ROTARY AIR ROTARY AUGER CANLE OTHER` <br /> t <br /> I HERFSY CERTIFY THAT 1 HAVE PREPARED TMS AP LPCATION AND THAT 714E WORK WILL NE DOUR M ACCORDANCE WITH RAN JOAOUIN COUNTY OMNNANCE@,STATE tAWB,ANb PALES ANO <br /> REGULATIONS OF THE SAN JOAOVIN COUNTY. HOME OWNER OR LICENSED A0101-11 <br /> SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIrY THAT BH THE PERFORMANCE OF THE VAINK FOR VAITH <br /> THIS PERMRT IB ISRVED,I SHALL NOT EMPLOY PERBONB BUNJECT TO WOPKMAN'@ COMPENSATION LAWS OF CALIFOrNIA.' CONTRACTOR'S Nrmmo OR mm eoNTMNOCTIgICNATURE CERTIrtER <br /> THE FOLLOYNNO: 'I CERTIFY THAT IN THE PERFORMANCE Of TIIE WORK FOR WHICH THBR PERMIT It ISSUED,I NHALL EMPLOY PERSONS RUSJECT TO WORTOMAN'0 C'OMPEJTIR N LAW@ Or <br /> CALIPoHONA.' THE ANT//�@ U@7 1""Lot'" <br /> ADVANCE FON ALL REOUIRED TNII Af It8@ AgEJ{22.COMMUTE DRAWIHO AT LOWER AREA PROVIDED <br /> StEnwd X_` Ti F--� �,Tleh d Aar 7 <br /> ROT PLAN Ibr—Iw Rerlrl 9-4 <br /> -"t <br /> o <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOGATIDN OF HOUSE RI'WAOE IRSMSAL SYSTEM aR Rw1P0@fO <br /> T. OIDLINE OF THE RIOPERTY,OPAMO DIMENSIONS AHD NORTH DIRECTION, ENPANRION OF AEWAOE WOMRAL RVRTFM@. <br /> 9. bIMENBIONFO 01JTUNF.11 A"LOCATION Or ALL EXISTING AND PROPOSED E. LOCATION OF WFLLI WARM RADIUS OF ONE HIMOOlb tWry FT. <br /> ITRUCTUPES,INCLUDING COVERED AREAS BUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE P1om"OR ADJOIMNO rY10IERrY. <br /> ail <br /> , <br /> f 1 ` '7777 <br /> I <br /> w <br /> .. <br /> podc5 � <br /> �(= ' <br /> '✓ I <br /> 7 OtPAR1tMFNT USE ONLY <br /> APeI}eerlew AecwvlwA <br /> Grew ImvwcUen SY b.Iw <br /> By <br /> hwPp lmpenllnrt - Dae <br /> Ir �3' /V„ d 6.1. <br /> be.IncRen ImPeellen d � I <br /> Celne.ertl.: ODI &e — I <br /> ACCOUNTING ONLY: AIDE <br /> {` I' PS CODES FEE INFO AMOUNT REAOT CH`7ECKI AA8H RECEIVEED�BY DATE PEIB @T/IFRNCE MEGIRFRT"wain INVOICE <br /> t <br /> L <br />