Laserfiche WebLink
' APPLICATION FOR WELLIPUMP PERMIT <br /> is SAH JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENYIRONMENTAL:HEALTH DIVISION <br /> P O BOX 368,446 N.SAN JOAQUIN ST..STOCKTON,CA 96201.388 <br /> (209)468.3420 <br /> ON-REFUNDABLE PERMIT �XPIRES I YEAR FROM DATE ISSUED <br /> !I' <br /> ICampi6t/In Tripfii/1/I i' <br /> APPEECATJON IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEHMIT TO CONSTKUCTANDJOR INSTALL THE WORK DESCRIBED.TINS AFPHCATroN IS MADE IN COM%IANCE WITH SAN Ill <br /> JOAM04 COUNTY DEVELOPIAENT TITLE.CHAPTER 9.1116.3 AND THE STAlJOARDS OFF am JOAOUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRDNLIEMAL HEALTH OOAS1om <br /> +4 .G4 � .QEr'flI✓r .J%"�CC/ IS CITY 7�•k 7�'f✓ <br /> JOB ADDJIE88lOR APNI !i S <br /> ,y dPARCEL SIZEIAPNP - <br /> OWNERAJME'SN '�N rCCTj E ADDRESS .O, "4 .760 <br /> .LcslL/��RIONE Bio 4z- <br /> CONTRACTOR W4(y .Q CN J(R' o73W " 'iAl]ClPE66�s�1(/ 22WL"YUC&5:Zz1ZSPI1ONEfPG�I�22-��TS <br /> cp ` <br /> AACTOA _. `p_ I gU 73 l ;I <br /> LIC/ ! ; PHONE/ .. ' <br /> TYPE OF WELVPUMP: ❑NEW WELL 0 REPLACEMENT WELL LJ MONITORING WELL N ❑OTHER <br /> 13 INSTALLATION ❑WELL BYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> II' i--1.N—E7 F—Ir H.P. DEPTH PUMP SrT_FT, FIRST WATER LI;VF4 O <br /> {TYPE OF PGMPJ !I' <br /> ❑DUT-0E-SERVICE WELL ❑GEOpHHyWAL WELL cl R SORIELfi' B - <br /> DESTRUCTION: GT/k,L� o., <br /> "A L� )'/'!(✓— - - k <br /> 1 <br /> INTENDER Ilii OF WELL - CONimEJCTION iPECRiCAT1oNiL <br /> "°�� A <br /> ❑IHO116TRIAL yrs <br /> ' ❑OPEN BOTTOM pM.Of WELL E%CAVATIOH M.OF CONDUCTOR CASINO O <br /> ❑DOMESTICIRYVATE ❑GRAVEL PACK1412E TYPE OF CA81NG18TFELJPVC DIA.OF WELL CA I. D <br /> L3AO <br /> PUBLICtMUNICIPAL -. ❑DRIVEN DEPTH OF OUY 6EAL? SPECJFICAYroN N . <br /> 13 WWGATIONEAO El OTHER GADUT SEAL INST4LLE6 BY ^L GROUT BRAND NAME E <br /> L MONITORING GETOUT SEAL PUMPED:❑Yr ❑NE CONCRETE PEDESTAL BY DRILL FR; Y. ON. S .I <br /> APPROX.DEPTH _ IOCKWO CHESTER BOX/STOVE PIPE 'I. g <br /> PROPOSED CONSTRUGTION1pElLNO METHOD:MUD ROTARY. 1R NOTARY . '{= I'AUGER CABLE OTHER <br /> — <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WRL BE DONE W ACCORDANCEWJTN SAN <br /> JOAOUIII CPUNTY ORDINANCES.STATE LAWS,AND FERES AND <br /> REGULATIONS OF THE 6ANJDAOuw COUNTY.HOME OWNER OR LICENSED AGENT'S BONATUAE CERTiFJE6 7NE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS IBSUEP,1 ALL NOT EMPLOY PERSON -SCY TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTNACTOR'S HIMHO OR SUB.CONTRACTWIO SIGNATURE CERTIFHB <br /> THE FOLLOWING: I IFY THAT IN THE PERFO CE OF THE WORIL FOR WNIOH THIS PERMIT IB ISSUED,I SHALL ELNKOY PERSONS SUBJECT TO WORMHAN'/CONIMNSATION LAWS OF <br /> CALIFORNIA.'THE T C WI ALL JIFgU1RFA INS/TAA�FK�Y/7XIN�/]'',A'Y},130/1 INi12E//Cp�MrR�E�TE�D7MWWNI AT LOWER AREA pp .yP. pL <br /> 019-4 X TLtW f:1C o.l G LT /l- !�—L/ ! DH. .1 `� 7y� . <br /> t moi i <br /> ! <br /> PLOT IIJW IW.wwB..W SwI.�_"w: . <br /> 1.NAMES OF STREETS OR MADS NEAREST TO OR BOUNDING THE PROPERTY. :, - 4.LOCATION OF HOUSE'SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> ].OUTLINE OF THE PPOPERIY,OIVM DIMENBIONB ANO NORTH OIRECTJON. 7 - EXPANSION Of SEWAGE DID SAL SYSTEMS. ' <br /> 7.DIMENSIONFD OUTLINES ANO LOCATION OF ALL EXJB7INO AND PROPOSED '+ 'l '° S.LOCATION Or WELLa WITHIN RADIUS OF ONE HUNOIIEO FIFTY FT. r <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,PRIVEYWYS.'AND WALKS.g lI ON THE PROPERTY OR ADJOINING PROPERTY, <br /> it f <br /> gO <br /> €1' <br /> , <br /> �Pz F <br /> I L <br /> El <br /> r+� <br /> < -- - - 14 <br /> ...,,,,.. i„..... ..,, <br /> I <br /> ps l <br /> - <br /> DEPARTMENT WE ONLY <br /> AwWlc.ekn A«epe.tl e� 1 I`�. � ,. ..,.,., 6]� l! o.1a f ! 1� Orr Jam✓ r <br /> Grout NylHctk.BT D.t. P,—"P-""By <br /> D— <br /> E it !�"e <br /> PwWrreB.n Ilre.eUen BT '' D.t. <br /> G.nmrll.: 4t hjqbmal?�Uk W <br /> ACCPUNTINO ONLY: AID# FACSr }. ,! IYIII` <br /> PE COPE/ FEE INFO OUNT PIFBSTTED CHECKAICASN, Ri avEl7 BY I - DATE POYMIT1SOMCE REQUEST NLIMSER INVOICE - II <br />