Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT WELL / Pg '�'tp <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAH FROM DATE ISSUED <br /> IC6mpl/t/In TFlplk/t@I <br /> APRICATION IS Hf RE BY MADE TO THE SAN JOACNN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOPC DEnFUSEO.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN AOD COVNR'DE4fl0� �TilLf,CHAPTER B-�7�,3 ANO e F,e��,�mCp �OHEALTH� 6ERVICE6,{NVIpoNM iLSRFJL 1 MBfON. <br /> Joe ADDREDSRR APNE f//�l � ,} 7 /�] yy <br /> OWNER'S NAME I7 Tf�//'�"_ WIi1�!'�YI ADORES6.'V.. nS)J !T�'-[^.4'/�`V)� "F-i7J L/ �7 7 PHONE!/ �L� �— <br /> CONTRACTOR CL� IC !J! �.s M ADDRESS �'t�[„ Lam. (/F/fAA��I LC/.7/I PHONE <br /> yG2-70G <br /> SUS CONTRACTOR F� ADDRESSIJ <br /> ��L/� C/ PHONE <br /> TYPE OF WELLRFMP. LLvfw WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER <br /> 0 INSTALLATION ❑WELL SYSTEM REPAIR ❑CPOIS-CONNECT REPAIR ❑VAPOR EXTRACTION WEII.E:f--a <br /> 11Avw <br /> N..0 nwa, ILP. DEPTH RIM?SET_FT. FIRST WATER LEVEL p <br /> RPF£OF R/MPR <br /> r ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL R ❑ SOIL RORIPIO R <br /> I Fy � �� <br /> O > <br /> .ESTRUCTIONx / <br /> INTENDED VSE TTPE OFW COPMTRUCTION SPECIFICATIONS p <br /> I ❑WousTPAL ❑OPEN eOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑DOMEDT ICRI6VATE ❑ORAVEL PACKFBIZE TYPE OF CADINO/q TEEL/P/C OWOF WELL CASINO p <br /> ❑PVBUCIMUNK:IPAL 00MVEN DEPTH OF GROUT BEAL iPECVICATIOR �' q <br /> ❑�IRMSE <br /> OATIONIAO ❑OTHER GROUT AL INSTALLED 6Y GROUT BRAND NAME E <br /> ❑MONITORINGSTOUT BFALPVMPPOT 13Y- [104.. CONCRETEPEOESTALBYORLLER:❑Vr ON. 5 <br /> EP <br /> APPROX.DTH 2-5D LOCKM CHESTER baX/STOVE PPE S <br /> PIOFOBTO CONSTRUCTIONgMNUNG METHOD:MUD ROTARY� AIR ROTARY AUOEp CABLE OTHER <br /> 1 HEETIY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE M ACCORDANCE WITH ILAN JOAULM COUNTY ORDINANCES.STATE LAWS,AND RULED AND <br /> REGULATIONS OF THE EAR JOACIUM COUNTY,NOW OWNER OR LICENSED AGENT'@ SIGNATURE CERTIFIED THE FOLLOWING!'I CERTIFY THAT M THE PERFORMANCE OR THE WORK FOR WHICH <br /> TMS PERMR M ISSLIED,I TMS <br /> OYPERSONSSUBJECTTO WDRKMAWIF COMPENSATION LAWS OT CALIFORNIA.'CONTRACTOR'S HIRING OR SU"ONTRACTMO SIGNATURE CERTIFIES <br /> THE FGLLOVTIFKI• 1 C RFI PNCEOF THEWDRLRMIT IS RSSVEb.!SHALL EMPLOY PERSONS EV6JECT TO YPORIOYIAN'S COMPE]PSATION tAWs OF <br /> CALIFORNIA.' C SA MI ADVANCE FOR ALL REOl6R��lf(f1/[FTION/AT 13//)1/BJi]1.COMPETE DRAWING AT LOWER AREA PROVIDED. 4//spy <br /> DIpW X_ - ___ THU Ll P Wt.(-NC C ( (Z <br /> PLOT PLAN To—1.S.e.l Sul. 'I. <br /> I,NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. ., LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE MI <br /> PROPERTY,OFVD DIMENSIONS AND NORTH OWCTPDN, EXPANSION OF SEWAGE DIBPO6AL SYSTEM@, <br /> 3.DIMFNNONED OUTLINES AND LOCATION OF ALL EXISTMM AND PROPOSED 6.LOCATION OF WELW111.8@"THIN RADIUS OF WIE HUNDRED FIFTY FT. <br /> STRUCTURE!,INCLUDING COVEPED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALX& ON THE PROPERTY OR ADJOtHM PROPERTY. <br /> r I : 1 1�✓C� 1'.25 <br /> n' <br /> L <br /> x <br /> AM "d <br /> 3 <br /> S@FNIGEb- <br /> /dC�j l! ALfIF I W r1 <br /> PAW... . <br /> 4EPARTMENT USE ONLY <br /> Abo..fi.A.e.plad BY 6-6uDLIb A,- J <br /> a'"IMp tI—ST D.I. an er /D.l. <br /> oMl,icllen Imp.clbn RY D <br /> t.,„n..ne,: <br /> ACCOUNTING ONLY; Aw FACE J �/ <br /> FE COOS/ FEE INFO AMOUNT REMITTTn CHEC RSH RECEIVED■Y DATE PERYNTMERVICE REQUEST NUMSFR INVOICE <br /> S C.f�'D 0 -� +� 81v�J ►a-a-� � 7 7� <br /> P.ih 4-1th Sart/_F.,d- 17711/471 <br />