Laserfiche WebLink
_ APPLICATION FOR WELLIPUMP PERMIT <br />_ j r y SAN JOAQUIN COUNTY PUBLIC HEALTH SER, -ES <br />L i-�3 ENVIRONMENTAL HEALTH DIVISION <br />3� P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />/ 12091 4683420 <br />It) c? i �` C NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br />IGmplata in Triplicate) <br />APRICATION IS HEIIE BY MADE TO THE SAN . AOUIN COUNTY FOR A PERMTT TO CONSTRUCT AND/OR INSTALL THE WOWC DESC WEED. THIS APPLICATION IS MADE N COMPLIANCE WRH SA <br />JOAQUIN COUNTY DEVELOPMENT TIRE, l]IAPTWI B-1175.3 )1ND 7HE STAR IS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERIRMS• ENV WM,,E TAL HEALTH ORIISION. <br />JOB ALnREsson APN/ ,L LJ L% (,L(,1�i . �% (/,�FT )G(,�,.�Y� tt` �i (.�' 1 pR, <br />OWNER'S NAME�C iP. �C,CI 1/ C1/)/. Jrnl.fin�1LJOORFse <br />a.,e wni.VWIVN I ` .-IF AODn<98 IN.. PIIOPE/ <br />TYPE OF WELUPUMP ❑ NEW WELL ❑ REPLACEMENT WEIl ❑ MONITORING WELL I ❑ OTHER <br />❑ INsTALLATION ❑ WELL SysTEM REPAIR ❑ CRO:ACON TEPAR ❑ vm o I EXTRACRON WELL <br />❑ <br />of PUMP) Naw 11 p6w. " DEPTH P11MP SET_". FIRST WATER LEVEE11 <br />, <br />ITrpE <br />❑ INDU6TISAL <br />❑OPER BOTTOM <br />DNl OF WELL EXCAVATION <br />pA OF CONWCTORCASklG <br />❑ DOMESTCMSVATE <br />❑ G vEL PACK/SQE <br />TYPE OF CASINGISTEHAPVC <br />qA OF VVETL CASING <br />❑ PUBUCIMUHICHPAL <br />❑gYVRI <br />DEPM OF GROUT SEAL <br />_ <br />SH4CEIOATIOH <br />❑ IWOGATIOWAG <br />❑ OTHER <br />GROUT SEAL NVI'mm) BY <br />GROUT BIIAPD NAME e <br />❑ MONITORING <br />OROTT SEAL PUMPED: Ely. ❑ Ne <br />CONCRETE 1`EOESTM BV DRILLER ❑ Vs ❑ No 5 <br />APWHOX. DEPTH <br />LOCI NG CHESTER BOX/6TOVE RPE <br />S <br />— RiOPD1:ED COH6TRUCHON/DRIWNO METHOD: MUD ROTARY <br />AIR ROTARY AUGER <br />CARE OTHER <br />I HESESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WOW WILL SE DONE N ACCORDANCE WRH SAW JOAOUN COUNTY ORDINANCES. STATE LAWS. AI0 RUES AN <br />REGULATIONS OF THE SAN )OAQUIN COUNTY. HOME OWNER OR LICENSED AGEW'S SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT N THE KFIMFMANCE OF THE WOW( FOR WHIG <br />TWSPERMRISISSUED,I6H WTEMROVPERSONS6UB TTOWOIH M-SCOM�TIONLAWSOFCALIFO MN -CONTRACTOR'SMMWGR6USLOMIVCTN06HONATURECEAT6# <br />THE FOLLOWING: - I CERTIFY THAT IN THE PERFORMANCE OF THE WOW( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORMMAN'S COMPLHSAITION LAWS <br />C/A1PT{IC11NT MOST C M NOHSM N ADVANCE FOR ALL KOIm1tD CIONS AT {TDBI Atl3S20. COMPLETE DRAWNG AT LDWER AREA P ... <br />si'w X 1lJ % ��-� TW - Dan \� <br />ROT PIAN <br />f . NAMES OF SREETS OR POADS NEAREST TO OR BOUNONG TIE PADPEiffY. LOCATON OF HOUSE SEWAGE OSP'OSAL SYSTEM OR PROPOSED <br />2. OUTIYE OF T/E PROPWTTV, GIV11K ONJNHBbP15 AND NONTH OeCCTION. EXPANSION OF SEWAGE OISPOSM SY67E1ES. <br />3. DIMENSIONED OUTUNES A LOCATION OF AUL EXISTING AND PROPOSED 6. LOCATION 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 />