Laserfiche WebLink
PPLICATION FOR WELL/PUMP PERM[" <br /> SANa0AOUIN COUNTY PUBLIC HEALTH SERviCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 copy <br /> (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> IComplolo In Trlplicalal <br /> APPLICATION IB INK SY MADE TO THE BAN"AWN COUNTY FOR A PERMIT TO CONSTRUCT ANDAIR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CIHAAFrrM 8-1115.3AND THE STANDARDS OF BAN JOAQUIN COUNTY MOM HEALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. A' <br /> JOB AODREBBroRR/A1PNI /O((/{JOL/ AloirAS k } e' q � CRY LASE J /J, PARCEL BIZVAPNE l�1/ Zp/T_e-K,63o <br /> OWNER'8 HAMEC�A/VQTy b,' e (J1 U"W1 CO /�1 O�III/ ADDRESS /6/0/ � Da FT13 ITEC.A-h F�� PHONES 36 4TJ <br /> CONTRACTORnO1'1L. Q i' / • V <br /> ADDRESS S LDL 1z-fi�' IJCE / PHONE S �/F+ <br /> BUB CONTRACTOR K/C/EI dde AOORE88 CIDL L*L, MIT I/ / PHONE• <br /> TYPE OF WELUPUMP� ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑R.PN, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> RYPE OF PUMPI <br /> ❑ DDT-OF-SERVICE WELL ❑ OEORIY6IUL WE11I BOIL BOMNO � fl <br /> ❑DESTRUCTION. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DGMFSTICI'f*VATE ❑GRAVEL PACKIBIZE TYPE OF CASINOISTEELMVC DIA.OF WELL CASINO O <br /> ❑ PISLICIMUNICIPAL ❑DRIVEN DEPTH OF BMW BEAL W4CIrICATION_ A <br /> ❑ IRRIGATONIAG ❑OTHER GROUT BEAL INSTALLED BY ORORR BRAND NAME E <br /> ❑ MONITORING , s' GROUT BEAL PUMPED: 11 Y. [IN. CONCSETE PEDESTAL BY DALLER: Vw [IN. 5 <br /> APPROX.OFFER ''^^d� /•1 qVw LOCKING CHESTER BOXISTOVE PIPE 5 <br /> PROPOSED CONBTRUCTIONIDNWNO MFFHOD: MUD ROTARY AIR ROTARY AUGERr)C' CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULE*AND <br /> REGULATIONS OF THE SAN""OLIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.1 SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWB OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHO"THIS PERMIT I*ISSUED.1*HALL EMPLOY PERSONS BUBJECT TO WORKMAN'*COMRMMTION LAWS OF <br /> CAUFORNIA.-/T1J/nARUCAMT MUST C2W ADVANCE FOR ALL REOURED INSPECCTI <br /> ON <br /> �S <br /> �.AT MSBI 404 e2yf.,ICOMPLETE DRAWINO AT LOWER AREA P ONDED. <br /> RIynM X I /f <br /> Till. +'I/,`0y, <br /> ROT RAM ID,-1.B W.I S.Ne 'I. <br /> 1. NAME*OF STSEETB OR MADE NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PBOMSED <br /> Z. OUTLINE OF THE EPOPERTY,GIVING DIMENSIONS AND NOM"DIRECTION. EXPANSION OF SEWAGE 1318MRAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PIIOFUSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT, <br /> STRUCTUAE8.INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING F`ROPERTY. <br /> AD <br /> e <br /> 0 <br /> 2 1998 i <br /> !1 _ <br /> SEP <br /> 1 L i veY <br /> PUB U.,:Nr UAI'UIN GOUpJ1y <br /> HEALTHY ..., <br /> s <br /> J... :ENVIROfy EF7V(GES <br /> n <br /> MTMFNt VSE ONLY <br /> AppNaabn AapaPlad BY De. Nr <br /> OrPU Impmllen BY ImPbBpn By ON <br /> O..I•mlbn B+n.elbn BY Om <br /> C.mnxrxr. <br /> ACCOUNTING ONLY:, AID# FAC* <br /> PE CODES FEE INTO AMOUNT REMITTED CHECKITMA6H RECOVER BY DATE PERMITISERVCE REQUEST MLMOM INVOICE <br /> 0/6 76 <br /> Pub.Health Sew.-Enviro.173(1197) <br />