Laserfiche WebLink
`PLICATION FOR WELL/PUMP PERMIT <br /> SAN b AOUIN COUNTY PUBLIC HEALTH SER%RIVES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES L YEAR FROM BATE ISSUED <br /> (Complete M TripRe{bl <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WIFII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOREBNOR/AJPN//� h--r- /J , PARCEL SIZE/APNI L` <br /> OWNER'S NAME/4�/.S+.1/dllrF-�GY/JS7;k.. /-20 I,LIW FS1.S/L� ADDRESS/A <br /> �CpT.))0� ,11,fe,AYU/4`/�.) PHONE�I � .fSV <br /> CONTRACTOR KLC/I�2LLc� C/c/Y✓'l" MAireP�T.iUJ AODREBq�r'm`t',) /�/Y>/CJ< -S/Z /7l�/[y/�UCI Rq� �r-/�fry:�T�i— <br /> BUB CONTRACTORFSOR/ ��JGP ic,T7'��� AODIiESy�Tp�u//GSI S�C/}i w-LICI �RI�/JpS-6 <br /> TYPE OF WELL/PUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MON(TORINO WELL I THER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CR088-CONNECT AFFAIR ❑ VAPOR EXTRACTION WELL I 1 <br /> ❑Ne ❑Fbptlr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI <br /> rrpp,y)) <br /> EIOUT-0E-orrvICE WELL ❑ GEOPHYSICAL WELL♦ SOIL BORING <br /> & B <br /> IESTRUCTION: <br /> INTENDED USE TYPE OF WHE CONSTRUCTION SPECIFICATION{J A <br /> � /I <br /> ❑ INDUSTRIAL ❑OPEN BOTOM GIA.OF WELL E%LAVATION X dA.OF CONDUCTOR CASINO �- O <br /> ❑ DOMESTICTRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/6TEEL/FVC DIA.OF WELL CASINO O <br /> ❑ PUBUCBAUNICIPAL ❑1'DRIVEN DEPTH OF GROUT SEAL /Z 3(7 SPECIFICATION -p-�, .-. <br /> ❑ IRRIGATION/AG VOTHEAS,jr Z-/j�{',Z/M -- GROUT SEAL INSTALLED <br /> [�BBjY�":Vgt RIGF�� GROUT BRAND NAME�G/// CCZY7c/ E <br /> ❑ MONNORING // \ 1 /' ,[ GROVI BEAT PUMPED: PT�Tw ON. CONCRETEPEDESTALBYDRUER:❑Yr [IN. B <br /> ApPRO%.DEPTH /lI/K7e�) dsc (�P/r///�) LOCKING C ESTER BO%/STOVE RPE 5 <br /> YY <br /> PROPOSED CONSMM"ONIMLUNG METHOD: MUD WH ARY AIR ItOTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER ANO <br /> REGULATIONS OF THE BAN JOAMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I MULL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIHEB <br /> THE FOLLOWINO: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE(FOR WHICH THIS PERMIT IB ISSUED.1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA: THE APPLICANT MUST CALL 211 URS IN ADVANCE FOR ALL MOM M INSPECTIONS AT LESS)/411,411,423. COMPLETE DRAWING AT LOWER AREA PIIOVIMO. <br /> 810"{6X TItIe_ DMa �/- �F`�r <br /> PLOT RAN RMI.OPE Te eeJal BeMe_�' <br /> I. NAMES OF STREETS OR ROA G NEAREST TO OR BOUNDING THE DIRECTION. <br /> tLpPj jkj, A. LOCATIONSIOOF N EWA SEWAGE DISPOSAL SYSTEM OR PPAIOBED <br /> 2. OVTl1NE OF THE RIOPERTV,GIVING DIMENSIONS AND NORTH DIRECTroN. SII EXPANSION OF SEWAGE dePOeAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE ProPERTY OR ADJOINING PROPERTY. <br /> ©C.f77aN5 l <br /> Aeeeptw By <br /> DEPARTMENT <br /> TMENT USE ONLY (� �f <br /> ApplbFebn /I �I A,. Uc'T` /c • ' <br /> Oreul Impxeen BY Deu I 1 P.np ImpeeHen By Go. <br /> DMIrintlen IPpaetbn BY D.I. <br /> DemineMM /1.D-"L <br /> ACCOUNTING ONLY: ND/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHE / A6H RECEIVED BY DATE PEMKINEAVICE REQUEST NUMBER INVOICE <br /> 0l 75f/=7 <br /> Pub.Health Se".-Enviro.173(1/97) <br />