FIELD DOCUMENTS_1998-2000 - Laserfiche WebLink

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SANWOPLICATION FOR WELL/PUMP PERMS W �r UIN COUNTY PUBLIC HEALTH SE T ENVIRONMENTAL HEALTH DIVISION7952660"'1 304 EAST WEBER AVENUE, STOCKTON, CA n.a' (209) 468-3420 /Z/`�F NON-REFUNUABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (I^ IONSTR C In LIpElabl � S 7 1998 ag/•�•�i APPLICATION IS HERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOAOn INSTALL THE'/AR(DE6CNBE0.TI08 A 1 MAGE IN COMPLI E YJTII BAN JOAQUIN COUNTY DEVELOPMENT TRIS CHAPTER 9-1115.3 AND T DARTOS OF SAN OA N COUNTY PUBLIC HEALTH SERVIOEB,ENVI MENTAL HEALTH DIMS , Joe AooREssroR APSE o•+ , l :U t 3e++ ' n Cle ne GnPCa•^/(S (SGQ DS) /vao ,DF WC-11 st /a F/Bvr CWNER'B NAM C NL-'F ' �- _� ADDRESS E�..o�:n /y/IQ�y CR r/yGO��/�TJ KRONER S/o-6S�-YJac ONTRACT NR L•I I ADDRESS J IJCs PHONE/ SISSISSISSISSISSS -'/' n / owl- d SUBCONTRACTORa�O 12; r e ADOMSGHa/��C.S 4YSS3 MIT k-�5/07 nroHEFS/O-3/S-S TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMEM WELL ❑ MONRONNO vvR1/ ❑ OTHER Cl INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL o ❑MP.v❑Rp•Ir N.P. DEPTH PUMP SCT—FT. Ran WATER LEVEL O (TYPE OF PUMPS ❑ OUT-0F6ERVICF WELL ❑ GEOPHYSICAL WELL/ ® BOIL BORING S ❑DESTRUCTION: tNTENDEO USE TYPE OF WELL CONSTRUCTION EPECIFICATIONI A ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION :O'LnC PS DIA.OF CONOUCTORCASINO O ❑ DOME9TC/PNVATE ❑GRAVEL PACXI E TYPE OF CASINOISTEELVVC AI1F7 OIA.Of WELL CASINO I//jq 0 ❑ PISLICRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL fDfu/ �YPISI �J SPECIFICATION C(•I.rp.rlL- /SroAlfMl/�r R ❑ IPAIGATIONIAO ®OTHER GROUT SEAL INSTALLED BY O CJAjLIYJ,rL�40� BMW BRAND NAME N/g E ❑ MONITORING GROUT SEAL PUMPED: ®Y_ 0N CONCRETEKIMICTALOYDRILIETC❑Yw ON. VIA S APPROX.OEPTN ISO LOCKING CHESTER 00XlSTOVE FIFE A/lll� J g PLOPOSEO CONSTRUCTIONI018LUMQ METHOO: MUD ROTARY AIR ROTARY AUGER CABLE OTHER UY /'rL �US� I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION MIO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,RATE LAWS.AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERMSMANCE OF THE VAR(FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S WNW OR WU ONTNACTINO SIGNATURE CER'MMIS THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO WHICH TMIS PERMIT IB ISSUED.I SHALLEMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF D}LIFOFWI�aCANTT MUST IA DA.VANCE AOR ALL REQUIRED INSI DONS AT CtOS�Sf-HSR. COMPLETE DRAWING ATLOWER AREA PROVIDED. l/3�/yT/�_,a� (11S�L- IT/ Ir �LJDytr� " QAJa lz- 2-98 a,be _ MOT PAN RAev.to Se•bl U-IP 'I.-- 1. IsI. NAMES OF STREETS OR ROADS NEARER TO OR Bo"M THE PAQPETTY. 4. LOCATION OF MOUSE SEWAGE 0181`09AL SYSTEM On PROFOSEU i. OUTLINE OF THE PROPERTY.OMNO DIMENSIONS AND NORTH OMECTION. EXPANSION OF 9EWAOE DISPOSAL SYSTEMS. T. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT. STRUCTURES.INCLUDING COVERED/AREAS SUCH AB PATI08,DRIVEWAYS,ANO WALRUS. ON THE PROPERTY OR ADJOINING P OPE1TY. - �._ DEPARTMENT USE ONLY Appllp.Ibn AeanPled BY DNP''//'��Mr OrmA Inepmllpn 0Y O.IS PMrq I�nps9en Sy O.I. Oe•NmBen In. xRbn B cemmpn..: ACCOUNTING ONLY: Moo FACS PE COD" FEE INFO AMOUMT REATTED CHECK1lCASH RECEIVED BY DATE P T/SERVICE REQUEST NUMBER INVOICE Pub.Health SEN.-Enviro. 173(1/97)