Laserfiche WebLink
APPLICATION FOR WELLJPUMP PERMIT � T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST WEBER AVENUE,STOCKMN,CA 95201388 <br /> (209)4683420 <br /> NONREFUNDABLE PERMfT EXPIRES 1 YEAR FROM DATE ISSUED <br /> W.ri In TFlplieat■I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9 1115.3 AND THE STANDARDS OF BAN JOAGUIN COUNTY PUBLIC NEALJN SERVICES,ENVMIONM VITAL HEALTH DIVISION, <br /> G_1 I <br /> JOR ADORES&OR APNI//�4L D CITY [' / /J// PARCEL 812F/APNI <br /> OWNER'S NAME DG . �P f !t( ADDRESS 1300-0 .5e.. rfc, 4/(C RIO E# 96/ oYj�s <br /> CONTRACTOR P�ES Z/,, /(C ADDRESS LACI a7>Jy7+IONE• 3Lj 3/_�9 <br /> SUB CONTRACTOR ADD7ES8 UCI PHONE I <br /> TYPE OF WELLRLIMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MOM-TOPING WELL S ❑OTHER <br /> L yI/n" ❑NBTAUATION ❑WELL SYSTEM REPAIR ❑CIIOSB-CONNECT REPAIR ❑VAPOR EXTRACTION WELL• J <br /> P.lr H.P. DEPTH PUMP <br /> ST/(J //" ❑H—)AP GET—FT. FIRST WATER LEVEL 0 <br /> RYPE OF RIAWI <br /> ❑OUT-OF.BFRVCj WELL ❑GEOPHYSICAL WELL/ ❑ BOIL BORING S— <br /> C <br /> ❑DESTRUCTION: L <br /> O <br /> NTENDFD USE TYPE Of WELL CONSTRUCTION SPECIRCATIONS A� <br /> ❑INDUSTRIAL jJ OPEN BOTTOM ORA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO OIT� <br /> ❑DOMESTICMRVATE ❑GRAVEL PACK/SIZE TYPE OF CABINOPSTEEUPVC OLA.OF WELL CASINO D <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUTSPITZ <br /> � <br /> SEAL SPECIFICATION R:1- <br /> e IRROATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND HAM <br /> L MOMTOR INOp / GROUT REAL PUMPED'13 Y-Yr Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. ON. S� <br /> APPROX.DE►TH 12- ■ LOCKINO CHESTER BOX/STOVE PIPE S 1 <br /> PROPOSED CONSITLUCTLONIDNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9E8Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE N ACCORDANCE WITH BAN JOAGIIIN COUNTY ORDINANCES,STATE LAWS,ANT/RULES AND <br /> REGULATIONS OF THE SAN JOAOUN COUNTY.HOME OWNER OR LICENSED AOENT-S SIGNATURE CERTIFIES THE FOLLOWING-•I CEPTl THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> j THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIRSATION LAWS OF CALIFORNIA.-CONTRACTOR-8 EPPING OR BUBCONTRACTRIO SIGNATURE CERTIFIEi <br /> THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF TIE WORK FOR WHICH THIS PERMIT IB IBOM.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFOPMA.' TIIE C TMMRJST CALL 24 HOUIS IN ADVANCE FOR ALL REGIARED P"PPF CCTIONS AT <br /> 42001 4404422. COMPLETE DRAWING AT LOW"AREA PPOVID iP <br /> BlErwd% 000, Till. /'i✓-�"�l. / !/ S Z / Ax4� 0.1. <br /> AOT RAN 031—t.S.r.I R.W. l to �OO 1 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMEN61ONED ORRIINFB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVEREO AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK B. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L{O rYl d. 4�wo� <br /> fR <br /> V44. <br /> °! <br /> 10,f��CCr-SS <br /> n ' � � �rSCs f111hr--+++111 <br /> Wcft <br /> _ a <br /> j.. €. . . . PAYAMEIV7 <br /> - <br /> . <br /> SAN JOADL IN QUNfY <br /> PUBLIC HEALTH SERVICES <br /> cNVIRONMENTA�HEALTH OIVIS!CN <br /> DEPARTMENT US[ONLY '7 <br /> Appie.11.n At—plM BY <br /> C.N Inq.etbn By D.. P.,P 1—0—BY 0.1. <br /> 0.rVRilbn In.p.ptlen BY D.t. <br /> Cemm.nt. <br /> 1 <br /> ACCOUNTING ONLY: NDI FAC, <br /> PE CODES F AMO UMT REMITTED ....A.. R...BY DATE P~TPSERNCB REOUEIT NUMBER INVOICE <br /> /109 2(fol, oa�s35 <br /> MY I 5/z000BSZ o <br /> e <br />