Laserfiche WebLink
h' <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST,STOCKTON,CA 95201.388 <br /> (209)468-3420 <br /> NON-REfUNDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CSR{PI{t{M TR4iwE.) <br /> APPLICATION IS HERE BY MADE TO THE BM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SM <br /> JOAQUIN COUNTY DEVELOPMENT <br /> ETR CHAPTER 8.111 5.3 AND TH STAND OF SAN JOAQUIN COUNTY NIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB AOORESSIOR A-PPNNO �^ / S (�.S/ i IZ CITYrJa A <br /> �+ PARCEL BQE/ARU <br /> OWNER'S NAME A/ ADDRESS 2 3 RHONE B 2 <br /> CONTRACTOR /Y D1/�F�r ADDRESS 2- )YLOr 4K#07-2 752-PHONE <br /> 6V6 CONTRACTOR ADDRESS UCB PHONE/ <br /> TYPE OF WEUjFUMP: ,21 INSTALLATION NEW WELL 13 REPLACEMENT WELL 1:3LR13ONONNO WELL F OTHER <br /> RM INSTALLATION ❑WELL SYSTEM REPAIR ❑CPM SS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL B J <br /> S ❑Nw❑R..I H.P.14 DEPTH RUMP 8ET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP <br /> ❑OUTdF$ERVM:E WELL ❑GEOPHYSICAL WELL I ❑ SOK BORIFIO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASING D <br /> ❑DOMESTIClPRIVATE D GRAVEL PACK/SQE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO D <br /> ❑O PVNIC/MVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATXON R <br /> d IRRIGATION/AG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONTTORW GROUT SEAL PIMPED:❑Y. ❑N. CONCRETE PEDESTAL BY DRILLFR:❑Y. ❑NP s <br /> A X.DEPTH LOCKING CHESTER BOIUSTOVE RPE s <br /> RM]POMD CONSTRUCTION/MLLJNO METHOD:MUD ROTARY AIR ROTARY AUGER CANE OTHER <br /> ,HE CERTIFY THAT I HAVE PREPARED THIS APRICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY OROINAICES,STATE LAWS,AND RULES AND {� J <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SKINATURE CERTIFIES THE FOLD WINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HNSNO OR SUM-CONTKACTIN I SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFO CE OF THE WORK FOR WHICH THIS PERIMR IS ISSUED,I MALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA'T MT T CALL]� IM ADVANCE FOR RLL REOI/IED INSPKTION{AT 120{I 4{{JM23.COMPLETE DRAWING AT RAWER AREA PROVIDED. <br /> NP$n.0 z �!/G�--� <br /> PLOT PLAN ID—U 60.1.1 SOP, •1. ' \1 <br /> 1.NAMES OF STREETS OR ROADS NEARER TO OR BOUNOHNG THE PRDPERTY. 4.LOCATION OF HOUSE SEWAGE DIS OBAL SYSTEM OR PROPOSED v <br /> 2.OUTLINE OF THE PROPERTY,UIVNNG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELL$WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ONTHE PROPERTY OR ADJOWNG PROPERTY. ` <br /> 3 <br /> C� <br /> PAYMENT <br /> BECEIVEA <br /> MAY 19 1995 <br /> `SAN'JOAQUIN_GO.IJNT <br /> PUSL1C.NEALPH$ERyj <br /> Cj <br /> ChVIFION (EN7'kL HEALTH.DI SIO:V <br /> MTIM B/T ONLY <br /> Apolb.tlon Aco.Utl 8Y Dm <br /> __ Gr.vl Irvp.ctl#_n 8, O.t. WmP In.p.ctbn BY <br /> D.O-P IrrP.oROn BY D.t. <br /> comm.I.: <br /> ACCOUNnNG ONLY: AID. FACE <br /> PI Cqm FSEINFO AMOU T REMTTCD ASH RECBVED{Y DATE PEANUT/ T MUM{61 INVOICE <br /> C <br />