Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> *"R'SAN JOAQUIN COUNTY PUBLIC HEALTH SER'li ,; <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 389, 446 N. SAN 209)JOADUIN <br /> 468 ST., STOCNTON, CA 96201-308 ^ F <br /> n /7(209) 46934201, 1l/\(v\J\ \jl�J(/ <br /> 1 200 cal. M cS-p � <br /> DY- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ^Lt^-} (Complete in TTipFleetel W DESCRIBED. <br /> JOAQUIN ION COUNTY HERE DE BY E TO PMENf THE.CN UI COUNTY <br /> O THE PERMIT <br /> STANTo CONSTRUCT O AN INDIN COUNTY P HEAN <br /> HEALTH eE11VICE8�ENWRONMENfAI HEALTH IN COMPLIANCE <br /> µCE/WRN S <br /> /� P �1 _PARCEL SIZFJAPNe /yI/�" <br /> N I L F- S C -T-5-y- a 3 � CITY / z& 1 PHONE# yy, <br /> JOB AppREeWOR AM T�J��fI`J <br /> I�FQ lFU F1r9(o//IJ2A/Y11/GI OR se 41 y�CO n LIc# 37'UTe PHONE y,2-7E7� <br /> OWNER'S NAME l / <br /> /, i /y /tJl w — ADDRESS •L"/ <br /> COMPACTOFk_I '/ LIC# PHONE# <br /> ADDRESS <br /> SUBCONTRACTOR ,,.�,, � _ <br /> IjJ-THER <br /> TYPE OF WELUPUMP: (3W NEWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL♦ ❑ VAPOR EXTRACTION WELL# J <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR FIRST WATER LEVEL O J <br /> E3N�.v❑Pwpelr H.P. DEPTH PUMP SET�FT. <br /> TYPE OF PUMw ❑ CVT-OF.SERVICE WELL [3 GEOPHYSICAL WELLl <br /> ❑ SOIL BORING E <br /> Fr�R 7�' <br /> EBTRUCTON: •_ 'lq C <br /> INTENDED USE / TYPE OF WELL CONSTRUCTION SPECIFICATIONS - • I S aL/�.hO <br /> ❑ INDUSTwAL ( e,1 Cl OPEN BOTTOM DIA.OF WELL EXCAVATION ��R DIA.OF CONDUCTOR CASING <br /> TYPE OF LASING/6TEEUPVC <br /> DIA.OF WELL CASING O <br /> ❑ IXIMESTICIPwVATE ❑GRAVEL PACK/SIZE SPECIFICATION R � <br /> ❑ PIIBLIC/MUNICIPAL Cl DRIVEN DEPTH OF GROUT SEAL <br /> IMGATIOGROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ MONITORING ❑OTHER GROUT SEAL PUMPED: 13 Y— ❑N. CONCRETE PEDESTAL SY DwLLER:❑Yee ❑Ne S U <br /> ❑ MONITORING <br /> APPROX.OFDTN LOCKING CHESTER BOX/STOVE RPE <br /> AUGER CABLE OTHER <br /> PROPOSED CONBTRUCTONR%tlWNO METHOD: MUD ROTARY AIR ROTARY (� <br /> 1 HEREBY CERTIFY THAT i NAVE PREPARED THIS APPUCATON AND THAT THE OOH(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND\n <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 WO(K FOR WHICH 1 <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMpm&AnON LAWS OF CALIFORNIA.' CONTRACTOR'S HINNG OR SU"OHTMCTING SIGNATURE CLAWS OF <br /> ERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPISN ' N 0 <br /> CALIFORNIA.' �P C T C A✓24 NOURS IN ADVANCE FOR ALL REOWIED/INSp/E��TIONS AT 12081{683{23. COMPLETE DRAWING AT LOWER AREA PR OVVIDE�D- /L <br /> rTitle /{ Dea / ( .J V tV <br /> slpnee x <br /> RAT PLAN (131.to 6u1e1 Sulo 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. OU-TUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE THINUSPRADIUS <br /> SYSTEMS. <br /> J. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 6. N THE R 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 PROPERTY, <br /> r'c5 e1- 1-4 v 3 on s �ruli sm A Cep <br /> INIIQS'7i(/� <br /> t7PAYMENT 41 . <br /> RF^1�f�FPs f� <br /> JUN 14 1995 <br /> SAr�CHEA <br /> cNVIRONMENTALLHEALTH DIVISI;.�n. . <br /> I <br /> ERPRTMENT VSE ONLY <br /> Application ADD%Xod BY DeN A. <br /> Gnxn Inp Uon BY Wte -u�-�J Pump ingoctIon BY p� <br /> DeeVwp Inpwlon Byf //�� De <br /> cannwne: oi� M7 LAJ14 kAl- p( Ja <br /> 1r0 OL M <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODER FEE INFO AMOUNT REMITTED CA-C- ICASH RECEIVED BY DATE PORMITISERVICE REQUEST NUMBER INVOICE <br /> 31p <br /> ------------ <br />