Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988.304 EAST WEBER AVENUE,STOCKT(K CA 95201388 <br /> (209) 488.3420 <br /> NONREFUNDABLE PENR.MII EXPIRES�1 YEAR FROM ORTE II?UED <br /> APPLICATION HI HERE Sy MADE TO THE SAN JOAOUIN I/ <br /> CONTY FOR A PERMIT TO CONSTRUUCT+ANWOR INSTALL THE WORK DEBCNBEO.THIS APPLICATION IB MADE IN COMPLIANCE WITH RAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 S.3 AND <br /> T1Ey�S`TANOAROS OF SAN JOAOWN COUNTY PUBLIC HEALTH SERVICES,ENVWONMEMAL HEALTH DA41110N. <br /> JOB ADORFSM-YI APN. Cm, f� <br /> OWNER'*NAMF���'- ���,� 4] PARCEL812FlAPN/ <br /> CONTRACTOR�� �'('gIP\ ADD11Ess �.� `�C \OC\L�1 FNONE <br /> ADdiE .3�fq-a��gp <br /> 88 1�3 n�1�COAa L1Q�t LC, PF�DNE/Y� l <br /> BUB CONTPACTpR <br /> ADDRESS [JCI <br /> PHONE/ <br /> TYPE OF MU,jPUNIp: ❑NE:N WELL ❑REPLACEMENT WELL ❑MONRORINO WELL/ ❑ OTHER_ <br /> ❑INSTALLATION ❑WELL SYSTEM REPA61 ❑CROss{ONNER pIEPNR ❑VAPOR F]ClIUCTgN WELL <br /> 11N.w 1'L.PNr H.P.�� DEPTH HEMP BET�fT. � FIRST WATfJI IEVEI "1 I <br /> R Of PUMPI O <br /> ❑OUT-0RSERVICE WELL ❑OEOPHYIRCAL WELL I ❑ 8011 BORING <br /> B <br /> DESTRUCTION - <br /> NIT TYK CONE TION pIc"01,14 <br /> 13 A <br /> INDUSTPoN ❑OPEN BOTTOM DIA.Of WELL EXCAVATION <br /> I� JPA,OF CONDII[TOR CASINO D <br /> DOMESTICFIBVATE ❑GRAVEL PACKIWD TYPE OF CAWNGMTEElIPVC DIA.OF WELL CASINO <br /> 11 O <br /> R/8UClMUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL _ SPECIFICATION <br /> A <br /> WWIATIONIAG ❑OTHER GROUT SEAL WSTALLED SV GROUT SMND NAMF / <br /> ❑MONRONNO 1 OROUT SEAL PUMPED:❑Y.. ❑N,, CONCRETE PEDESTAL SY DRILLER❑Y.. ❑N. 5 <br /> APPIIOX.O[/TN \ O LOCKING CHESTER SOX/STOVE PIPE M <br /> PROPOSED COINTRUCTIOMMMLLJNO MITTHOO: PAW RDTARY_ NR ROTARY —AUGER_ CASLE OTHER <br /> 1 NEWRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL SE DONE IN ACCORDAWf WITH SAN JOAOUIH COUNTY ORDINANCES,STATE LA, AND 11VlEB AND <br /> REGULATIONS OF THE BAN JOAOIRN COUNTY. HOME OWNER OR UCFNSED AGENT'S SIGNATURE CERTIFIEB THE POLLOWRIG:"1 CERfIpY THAT iN THE PE/60RMANCE OF THF I.ANDORK FvueOR ANH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER60N6 SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S WRING OR SW{OMMCTING BIONATUIIE CEMIFlEBf <br /> THE FOLLOWING: I CFpRKY THAT 111 THE PERRORMANC[OF THE WOR[FOR WHICH THIS pERI.IR 1*IBBVEC,I SHALL EMPLOY PENTONS BUS.IECT TO WORIORAN'S COMpBMBA"I"LAWS OF CALIFORNIA.* THE APPEICANT MUST CALL'\N.�,N,OUI4 W ADVANCE <br /> -Oil ALL PKQ%Xf M INSPECTIONS AT 12CAl NB1S477. COMPUETE DRAWING AT LOWER AREA PROVKIVOO <br /> SISnW X P V`` !'Nrr�Y. _ �`\. \�QQ Y� D— <br /> n <br /> ROT RAN ID,ww to 6-1 S— <br /> t NAMESOF STREET*OR ROADS NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED r <br /> 1 OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, rc <br /> 3 OIMENWNEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WRNIN RADIUS OF 0-9 HVNOWD n'TY R <br /> STRUCTURES,NCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALX6. ON THE PROPERTY OR ADJOINING FROPERTY. <br /> NoRZ� <br /> ........ <br /> ..... ..... ,.. <br /> '�. .. . <br /> ....... <br /> wIlta <br /> �.... .. .. �;.firF <br /> t... : : . <br /> 2 <br /> O. !...... :. .. ....: . <br /> iv PA <br /> C� ` <br /> .... ;.. <br /> :... . <br /> . .. .. .>.... :. . .. <br /> yr,fr � <br /> OEPAPIMENT USE ONLY <br /> Applb.,len A—PPPb By_ (_ A— <br /> r <br /> Grout Inp.Ptbn ar_ 0.,. P—p bnpsllon By <br /> OstrwU.n Inp..,lorBy ON. <br /> � C.mmeM. <br /> ACCOUNTING ONL NOI FAC♦ <br /> PE COOES FddOc AMOUNT RMIITTED NK /CADH RECOVID Sy DATE 1BlA110 KI REG&RIST NL)N661 INVOICS <br /> I o? , <br />