Laserfiche WebLink
►-.�.--'-� 1 �'. 'PLICATION FOR WELL/PUMP PERMI1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION a I /►� (/ l <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 952Q? *; <br /> (209) 468-3420 x 1 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A PC- 1 x1 <br /> (Complele In TrlpReell) <br /> APPLICATION 18 NErIE BY MADE TO THE SAN JOAQUIN COUNTY Fon A PERMIT TO CONSTRUCT ANO/on INSTALL THE WOW DESCRIBED.TIIIB APPLICATION 18 MADE IN COMPUANCE WITII SAN <br />(. JOAQUIN COUNTV DEVELOPMENT TITLE,CHAPTER 9.1116.3 AND T EBT HOARDS OF BAN JOAQUIN COUNTY PURLIC I{EALTIf SERVICES.ENVIRONMENTAL N€ALTH OIVIMO <br /> i JOB ADDRESSOR APNI CITYtt PAG� IF SIZF/APNI <br /> OWNER'S NAME . •F l l PI ZONE <br /> . ADORESB(n,�3 sell 1,vtI1 I►' �}� / <br /> j CONTRACTOR ADDnFeB Fn t'6)( lop, UCI PTtoNE I L.�LJtI <br /> SUB COIRRACTOR AODRF.98 i LIC/ M40NE <br /> TYPE OF WELL/PUMPI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTT OnING WELL <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT nEPAIYI �R EX�RA � <br /> / f �/ fJJ�A��CC//T N w[u I ✓ <br /> ❑N•w Repdr H.P. DEPTH PUMP BET FT. l 4•��` / FIRBT �TER�i� Q <br /> (TYPE OF PUMP) / �� <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING / <br /> --t r .., 1, .. 6...�„,:y# ,:J; i'.; - ±• • y•. ._ . <br /> N TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> pQ WWOTFILAL ❑OPEN BOTTOMr DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> ltiI POMEaTICIMaVATE GRAVEL PACK/SIZE TYPE OF CASINO/BTEEL/PVC DIA.OF WELL CASINO p <br /> {L-J� PUBUC/MVNICWAL DRIVEN DEPTH OF GROUT BEAL BrECIFICATION it <br /> ❑ IRRIGATION/AG ❑OTHER GROUT BEAL IN87ALLED BY GROUT BRAND NAME / <br /> Q MONITORING /n� I GROUT BEAL PUMPED: ❑YN [IN. CONCRETE PEDESTAL BY DRILLER:❑YM �No d <br /> APPROX.DEFTH (l LOCKING CHESTEn BOX/STOVE PIPE d <br /> PROPOSED CONSTPIUCTIONIDIILLING METHOD: MILD ROTARY AIR ROTARY AUGER CABLE OTHEF{ <br /> t <br /> _ I HF9EBY CEI1J►FY H/1T I HAVE PREPARED THIS AP`LICATION AND THAT 111E WORK WIU.BE BONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE 1,AWS,AND PULEe AND <br /> REOVLA'IONS QF, NE SAN JOAOU)N COUNTY. HOME OW R OR LICENSED AGENT'S SIONATURE CERTIFIES TILE FOLLOWING:-I CERTIFY THAT IN THE PERFQFIMANCE OF,THE WORK FOR WHICH. <br /> TINS PERMIT.1 S EO,I gILALL P1,OY PERSONS S'�I.'CT To WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S IIIRINO OR BVD-CONTRACTING IRGNATIJRE CERTIIFIES'` <br /> IRE FOLLOW 'I CERTIFY T IN NE PERFO R/dA c/E OF 711E WORK FOR V4711CII THIS PERMIT IB IBauto,I BIIALL EMPLOY F•Ene0 Na SUBJECT TO WORKMAN'S COMI'QISILT10/tLAW4 OF+' ` <br /> ,ALI(OF"A.1} PPUCANT C Z HO AD I:E FOR ALL REGUIRFG�i?4SPWTI' `iMi pel A 4422.'COMPLETE DRAWING AT LOWER AREA PROVIOED,� � <br /> Big <br /> PLOT PLAN ID­to So-lel Sod. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On SOUNDING TIRE PROPERTY. 4. LOCATION OF/ROUSE SEWAGE DISPOSAL SYSTEM QIII,q 0TOBED <br /> !. OUTt"OF TILE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAh:�YSTEMS.- e'.* ' ' <br /> 7. DIMENSIONED OUTLINF8 AND LOCATION OF ALL EXISTINO AND PROPOSED S. LOCAL PON OF WELLS WITILIN S OF ONE NUNDPIEr•fr.TY FT. <br /> STRUCTURES,INCLUDING COVERED AREA@ SUCH AS PATIOS,DRIVEWAYS,AND WALXB. ON TILE PROPERTY OR ADJOIN", - <br /> i <br /> f r��, r <br /> I 1I 1 <br /> , <br /> .,d�.r+ 9 <br /> t/ <br /> {I <br /> 1 <br /> ' ��� 6 <br /> I� <br /> i <br /> Q <br /> 8 <br /> PAY WNT <br /> fl. <br /> AP 199 <br /> SAN <br /> •. •.Pl1B <br /> DEPARTMENT USE ONLY <br /> APPS.Nbn AN.pleA BY I•./V f V`-" ,. .- } •1 <br /> D • G MN� 5 <br /> grew I_Peell_BY Dot* Imp lmp.ellen By <br /> --Date ! <br /> r5 <br /> e.v,atkn hrP.atlon BY D.t• <br /> CemmerMr: <br /> ACCOI/NTIN0 ONLY: AIDS FACS <br /> PT COM FEE INFO MOUNT REMITTEb CllIE"CKIMAILI RECEIVED■Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> t <br /> Pub.Health Serv.-EnVlro.173(1/97) <br /> Ik, <br />