Laserfiche WebLink
' APPLICATIOIEkfOR.WELLIPUMP PERMIT <br /> SAN JOAOWt1 ; ' , ; PUBLIC HEALTH SER� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKfDN, CA 95201-388 <br /> (2091 468342D <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEARR. FROM ATE ISSUED <br /> APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT <br /> ' ALL THE WOW(DESCRIBED.THIS APRI•TION is MADE IN COMPIJANCE WTTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OO/FF1 SANJOAQUIN COUNTY WBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESSX)RAFNI Ok l0/E2H4 iJ✓`IJ CITYY fj✓2aCU ,1 ,(J /� PARCEL S¢EIAFNS <br /> OWNER'S NMIE nL e�ar/l�o('� �9/'j[(/G ADDflE562-.T 1Q(1�1441G/fFV 1lI l/✓' F /,n 1 PHONEI( �j18-37�-,4 Sao <br /> CONTRACTOR [ t:gl;L Dr/1llV� i SPI ADDIG66/V/�//IT ly(udllp aL. UCe .'?06 zcl( WIOnfE ydS_Q < <br /> SUB CONTRACTOR <br /> ADDRESS M/ <br /> IIqq MORE <br /> TYPE OF WELL/PUMP. 101 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTA TION ❑ WELL SYSTEM REPAIR ❑ CROS6{ONNER REPAIR ❑ VAMfl EXTRACTION WELL/ <br /> (TYPE OF PlIMP1 <br /> ❑N—❑R,,, M.P. DEPTH PUTAP ST FT. FIRST WATER LEVEL <br /> -- D <br /> ❑ OlR-0FSEflNCE WELL ❑ GEOPHYSICN WELL I ❑ SOIL BORING B <br /> 1-1 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONFTAVCTON i PECIHCATIO F p t/ A <br /> 101 INDUSTRIAL q❑F OPEN BOTTOM DIA,OF WELL EXCAVATION R DIA.Of CONDUCTOR CASING <br /> ❑ DOMESTICTRIVATE ([]GRAVEL PACK/SIZE �f'2 TYPE Of CASINGISTEELrtNC Q Py�,1 O <br /> �.iS�-{ P✓C DIA-OF WELL CASING ? /� O <br /> ❑ PUBUCRIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ^ SKCIFICATION A <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY l/1••I(IG✓� GROUT BRAND NAME E <br /> MONITORING GROUT SEAL FUMKD; ®Y— ❑N. CONCRETEPEOMALBYDWLLF0.❑Y.. ❑N. 5 <br /> APfTO%.DEPTH LOCKING CHESTER BGX OV,MK J, <br /> FHOPOSE0 CGNSTRUCTION/ DUNG METHOD: MUD MTAIEY_L/--AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AFFIJCATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH 6µ JOAQUIN COUNTY 3WINMCE6,STATE LAWS,AND RULES ANDREGUUTIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MUDWING:•I CERTIFY THAT IN THE KIVOIRMANCE OF THE WOW(fOq WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMKOY KB60NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUB{ONTRACTING SIGNATURE CERTIFIES <br /> TILE FOLLOWING: •1 CERTHY THAT IN THE KILFORMµCE OF THE WORKWORK FOR WHICH THIS KAMIT 16 ISSUED.1 SHALL EMKOY PERSONS SUBJECT TO WORKMµ'I COMPENSATION LAWS Of <br /> CwIJfO1W1A.•//(TH/�E APPl1CAHT MWT 2I Iq{pS 1N Apyµ F.Oq ML REQUIRED(NIP/EC^`TpW AT/12O614S6313]. COMPLETE DRAWING AT LOWER AREA PIgNOEO. <br /> slpT.ax /.C/OM SAL/LI1CY_i--P✓f-IFIJY/E/LNG///IY///1M TIo._I J el�!©�/.S� 0.'. IDI9 _ <br /> PLDT FLAN IDI—I.6 .l SUM Ia <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PHDKRTY, 4. LOCATION OF HOUSE SEWAGE DISW SAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE FFOPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIGPOSAL""EMS. <br /> O. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING µO PflOPO6E0 S. LOCATION OF WELLS WTyHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON lflE PROPERTY OR ADJOINING PROKRTY. <br /> .. ...... <br /> Si Tom' <br /> DEPARTMENT WE ONLY <br /> APPIiuJan Anc.pld 6Y .3u-5 5 <br /> Gmul 1n. on BY D.I. Punp Iloon By Du. <br /> Dsll�cllon Hvp.clan By <br /> D.I <br /> Comm <br /> ACCOUNTING ONLY: NO/ EAU <br /> K CODES FEE INFO AMOUNT PEMIRED CHECKIrCAFH RECOVED BY DATE PEFMITIFDWICE AEG EST NMA6WI INvoICE <br /> �h01 CU 5 Ill(Z <ue -� Ioja S bfl C <br />