Laserfiche WebLink
.. APPLICATION FOR WELLIPUMP PERMIT . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 44S N.SAN JOAQUIN ST., STOCKTON.CA 96201388 1� <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ((Complete in Triplicate) c"' <br /> APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPUAWE'.11TH Err. <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.7 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> v4tiv ✓�f'44u xSS-760- 3 <br /> JOB ADDacca,DR.uwP ZS(�" l—,fiJr S j/,<Y/ �.'r..rT,4 /� clTnv —�N�4/ S•/s I.ny L�� PARCEL 61zE//ryAPN♦ �. <br /> OWNER'S NAME �7 CJ,l(-,^ QL/l.�/T/ ADDRESS r- 199Y-7&'& ✓.f'P4441�-C'} y� ;DRONE <br /> CONTRACTOR ADDRESS X1LICEY/ru<J,j CY RIONEE '21ae <br /> SUB CONTRACTOR ADDRESS LACI PHONE I <br /> [�CTYPE OF WELL'PVMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER I .,,,'_J l.E�'ti - <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT REPAIR ❑VAPOR EXTRACTION WELL F U <br /> ❑N—❑F—P N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> rTVPE OF PUMP) n <br /> ❑OUT-OF SERVICE WELL 13 GEOPHYSICAL WELL P SOIL BORING F/f�' �c/JS <br /> ❑DESTRUCTION: 6 r Z)- <br /> INTENDED Ue4 TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z /.,L19 M- DIA.OF CONDUCTOR CASING O <br /> ❑DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELP C A.//4 DIA.OF WELL CASINO O <br /> ❑PUBUC�MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑INYGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING // GROUT SEAL PUMPED:C3 Y_ to CONCRETE PEOESIAL SY DRLLFN'❑Y. CIN. $ <br /> APPROX.DEPTH b r /. LOCKING CHk STEN BOA/STOVE PIPE S f'. <br /> PROPOSED CONSTRLICTIOWDAJWNO METHOD: MUD ROTARY AIR RUTMY____AUGER CABLl OFHkH /QCcL Q•�N v <br /> f 1 <br /> I HERESY CERTIFY THAT I HAVE PREPARFU THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND HOLES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH r`I <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAJFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THF 1-0LLOWINO: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMM'S COMPEN*ATION LAWS OF <br /> CALIFORNIA' 'POC ANT MOST CALL K HOURS IN ADVANCE FOR ALL REU <br /> GRED INSPECTIONSN 7. <br /> / AT IlOeI 411, COMPLETE DRAWING AT LOWER AREA PHO VIDEO. <br /> Blen.;7� <br /> - TIn•� lct jJ Fc r �/9:e ttCe-1JT D.0 2! Cf <br /> PLOT RUN IDr IoI.NS OF STREETS OR ROADS N BT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. ONE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTI HIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WAL". ON THE PROPERIY OR ADJOINING PROPERTY, C <br /> F <br /> FEJIE{ / <br /> Piz 0i�c•:t r.7 <br /> Y �•E <br /> Serif r�a,v <br /> l/ o <br /> 14-x•'✓�� L�.SEUCD l=Gi.+.._. i A•�� <br /> DEPMTMENT USE ONLY z <br /> AP0l 11on AGo.l.d By \ .. D.I. J Mu <br /> man%_'_By Du. vvmP Luv«non By <br /> D.Iruclion InP«(m BY •Co—o' nn'rn ��l ,1J(i/ZOG7/ <br /> 0,1M 121_41 <br /> ACCOUNTING ONLY AIDE FACE <br /> PE COD" FEE 1H10 AMOUNT REMITTED CHFCIUF CASH AEC OVED BY DAT ROVAITIEFRVICF REQUEST NUMSSA INVOICE <br /> _W03 003 �� <br />