SU0002249 - Laserfiche WebLink

Home Browse Search

0 APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - 44 304 EAST WEBER AVENUE, STOCKTON, CA 95202 0 . (209)468-3420 f NON-REFUNDABLE_PERMIT EXPIRES I YEAR FROM DATE 130ED icavlelf IN TTIpRn111 APPLICATION 13 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORT(DESCRIBED.7109 APPLICATION 19 MADE IN COMPLIANCE mill SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1 116.3 AND THE STANDARDS OFr CAN/JOAOU,N COUNTY PUB C HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBKIN, JOB AVORF98MR APN! 1 O-�TQ 7 `)r akc-61, � ._ L`[L_CITY44 PARCEL 9IZVAPN/ OWNER'R NAME r AOUREBR S PHONE.L? �yr CONTRACTOR AVOW@# HOZ 4j% �e , PHONE re I PUB CONTRACTOR 11rN1E11 � � [ID/ PHONE! TYPE OF WELL/PUMP: ❑ NEw WELL ❑ RERACEMENr wELL ❑ MONITORING Y11Eu s ❑OTHEn, 611-k4"t L . ❑ M91ALLATION © WELL SYSTEM REPAIR ❑ CRO99-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLF J ❑New©nww' H.P. DEPTH PUMP SET IT. .FIRST WATER LEVEL p TFYPE OF PUMP] ❑ OUT-or•BERvicE WELL ❑ GEOPHYSICAL WELL! Q som eORINO 9 ❑OESTRUCTION� INTENDED USE T OLWELL CON&TRUCTMIM SPECRFICATIONf A - I ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION OIA.OF CONDUCTOR CASINO O 111t b ❑ OOME9ricmmvATE ❑ORAVEt PACKMIYE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASINO p i ❑ PUSUCIMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION uAt R 02I ❑ IRRIGATIONIAG ❑OTHER OROUT REAL tHRTALLEO BY y OROUT BRAND NAME E 11 MONITORING �� GROW REAL PUMPED:❑Yr 0 Ne CONCFETf PEDESTAL II DRILLER;❑Yr ❑Ne S APPROX.DEPTH LOCKING CNEBFER Box/STOVE PIPE S PROPOSED CONfTRUCTIOMILMRLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER____ I WREBY CERTIFY THAT I HAVE PREPARED THIS APYLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADVIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE fOUOtMNO:'1 CERTIFY THAT IM THE PERFORMANCE OF THE WORK FOR YYHICIT THIS PERMIT IS SUE 1 L NO OY R SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONFRACTMO SIGNATURE CERTIFIER THE FOLIO C 7 H THE ATO AHC#OF THE WORD FOR WHICH THII PERMIT'IR 198M.19HALL EMPLOY PERSONS SUBJECT TO WORWAN'S COMP'FNSATION LAWS OF CAUFORM C M S CA HO IN ADVANCE FOR ALL MOWEDj!7NG AT 1�R 4aif f OMPLFFE AT LOWER AMA PROVIDED. ela'+aa x Tme PLOT RUIN IDtew to Beelel Sade 'le 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE GRSP M SYSTEM OR rYIOPOBEG S. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRE TION. EXPANRION OF SEWAGE DISPOSAL SYSTEMS. Z. DIMENSIONED OUTI-l"FS AND LOCATION OF ALL EXISTING AND PIgPOSE6 S. LOCAMN OF WELLS WITHIN PAWS OF ONE HUNOREO FIFTY FT, BTRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK& ON THE PROPERTY OR ADJOINING PROPERTY. I .y. : : ;....:.. r . r s tv Po 9;7z� e ONLY IJp Applleetlen Aaeaplad BF Oel• Q i Aree Ototml I-pmtlen BY Dole p hwpeetten RT Dene R.wnuetlen 1, 0.aetlen BY u 1 Cerw,'ne,Ne: Z� ACCOUNTING ONLY; AID* FAC/ Lj— PE CODES FEE INTO AMOUNT REMITTED CHECK/ICARH RECEIVED NY DATE PERTNITTSERVICE REQUEST MUMS@t INVOICE 5c 6 pub Health Serv.-ERviro.173(1197)