Laserfiche WebLink
APPLICATION FOR WELL(PUMP PERMIT V 'Zo <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r, '5 C S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 00'?-12-0-0­� <br /> RO,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA%%1388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2Tripliuu) 6-d O 0 6 <br /> APPLICATION IS HERE Y MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANA/OR INSTALL THE WORK DESCRIBED.THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9 1 1 1 6.3 AND THE ST2DAA OF SA OA0014 COUN(T((Y.L{�PPUBLIC HEALTH SERVICES,ENVIPDNMFNTAL HEALTH DIVISION. <br /> JOB AD,RRESS/DRAPNf N/W Corner Liberty/MacKyille CITY �A/`�' PARCEL8IZE/ApNf 486 acres <br /> OWNER'SNAME Las Lomas ADDRFSS 13852 E. Peltier Rd. ,Aca",9f <br /> CONTRACTOR Purviance Drillers, Inc ADDRE6VOB 64rLinden ucf 377923 PHONFP87-3554 <br /> SUB CONTRACTOR ADDRESS <br /> LICE PHONE f <br /> TYPE OF WfUjPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑ MONITORING WELL A ❑OTHER z❑INSTALLATION ❑WELL SYSIFM REPAIR 11CROBS.CONNECT REPAIR ❑VAPOR E%TRACTION WELL f <br /> Turb 0N-0 R.D.I, M.P. 250 OEpTH PUMP SFT300 FT, FIRST WATER LEVEL <br /> RYPE OF RIBRPI <br /> ❑OUT-OF SERVICE WELL ❑GEOPHYSICAL WELL f ❑ SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA,OF WEIL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> ❑OOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA OF WELL CASINO O <br /> ❑PUBIUCMUwc IPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑INIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME f <br /> ❑MONITORING GROUT SEAL PUMPED ❑ ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne <br /> APPROX.DFPEH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONBTTIUCTION/DRIWNO METHOD. MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORONANCES.STATE LAWS,AND RUILF8 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR CH <br /> THIS PERMIT 16 ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT10N LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING DR BUD-CONTRACTING SIGNATURE CERT <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOPXMAN•4 COMPEHGATION LAW F <br /> CALIFOR APPUC AN CA N Fp VRB IN,AOVANCE Fon ALL RFOtARFO INBPiCTTONB AT Rtl <br /> oel 4 �47l. COMPLETE DRAWING AT LOWER AREA PPK7 VIDEO. <br /> 6ro� d TIII. Corp Secretary Da. 7/15/97 <br /> PLOT PLAN ID­to Be.I.I 6e.1. [o <br /> 1NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDpOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 6YSTEM8. <br /> 3. DIMENSIONED OUTLINF6 AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLS WITHIN RADIUS OF ONE LRINORED FITTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK 8, ON THE PHOPERTY OR ADJOINING PROPERTY. <br /> � w <br /> Ir 4w <br /> t <br /> F <br /> .. .. S.. <br /> PAWAENTIZI- <br /> REC7 <br /> ii/ED <br /> JUL 1:6 1997.' <br /> SAN JOA(,.•Iv COUNTY <br /> RVICES <br /> .. .. .. ! :ENVIRONMENTAL.HEALTHD:WSIOL.. <br /> DEPARTME T USE ONLY �o <br /> Groh Imp.ctbn By D.ta_ HrmD bvoecllen By <br /> De.mcllen lyrpectlen By _ D.[. <br /> -7 7 �-.�. r �,s �t.� ,'i 11 r �^T��� �.-r. C� ✓7 _ G�iC� <br /> AC COUNTING ONLY: AUDI FACE ,..+ <br /> PE CODES FEE INED AMOUNT REMITTED CHECK IC A8H IIEC13VEO BY DATE �1fEFtMJjlffAVIC'E'1LFOtfFYT.21j�MBEq INVOICE <br /> p t• D'+�D'f0 <br />