Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICIP <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P•0• BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLMATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCTIANDIOR INSTALL THE WOR(DEB FVBED.THIS APPLICATION is MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNNT.1Y,MOM HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.JOB ADOREOMN APP�L#. PL4 LAA iA /e IT^ <br /> OWNER'BNAME S(TIIIA Of Cle";An PMCELSIZEIAPNI c-�1I-C f <br /> DoAa CL$ w,s, De .Ad4a� /o ADDRESS 1900 POLUCII St. 1211 Floor E U;11, CA PHONE# sfc wt-gsbc <br /> co amcFSR . 0.u <br /> L1 /� 1,� 1 M� LK•/ FNIGNE-°� <br /> SUBCONTRACTOR kp17111rtd•TCSPr4ti' � X -S'}H =A ADDRESS 1504C.4I'Wrl1R CIO <br /> C fill 1 ertRlrRf_LM{y%S1b5 %low <br /> TYPE OF WFLI'IJM t ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I q1 OTHER GPr/µydropuncl, <br /> ❑ NST N ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> 13N.0 Rop.1, H.P. <br /> Rt9.b , P SFT FT. FIRST WATER LEVEL <br /> HYP OF PUNT% DEPTH PUMP __ O <br /> p( -{ ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SON BORING <br /> p DESTRIMTON: 1 1e- PoANad CeGrow} ° <br /> A-. <br /> INTENDED USE Type OF CON{TRUCTION SPECIFICATIONS❑ INDUSTRIAL 11 OPEN BOTTOM DIA,OF WELL EXCAVATION A <br /> ❑ DOMESTM,PRSVATE ❑GRAVEL PACK/BRE DIA.OF CONDUCTOR CASINO D <br /> ❑ <br /> TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO w@IMIMUNMroAL 11 DRIVEN D <br /> ❑ <br /> DEPTH OF GROUT SEAL SPECIFICATION IRIIHATIONIAG ❑OTHER R <br /> ❑ <br /> OROHR SEAL INSTALLED BY GROW BRAND NAME <br /> MONITORING GROUT <br /> (`� GROUT SEAL PUMPED: ❑Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y« ❑N. S <br /> AIPROX,pFPrN ` 1� TYP.� LOCKING CHESTER BOXwOW PPE <br /> PROPOSED CON/T MMIODI0Ll1NO METHOD: MUD NOTARY / S <br /> AIR ROTARY AUGER CABLE OTHER CPT <br /> I HEREBY CERTIFY THAT I "A IN COU THIS AP%ICATgN ANp THAT THE NbNE(WILL BE DONE IN ACCORDANCE LWTN BAN JOAWIN COUNTY ORDINANCES,STATE"We,AND RULES AND <br /> REGULATIONSPERMIT 1 OF THE SAN JOANOT COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PEWORMANCE OF THE WOR(FGR WMCN <br /> THIS PERMIT IS ISSUED,1&TALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBLONITMCTNG MONATURE CERTIFIES <br /> THE FOLLOWING: •1 CERT"THAT IN THE PEWORMAME OF THE WOM FOR WHMH THIS PERMIT IS ISSUED,1 SHALL EMFLOY PERSONS SUBJECT TO WOROHAN'S COMPENSATION LAWS OF <br /> i C 7 MIST CALL 2/HOUR°IN ADVANCE FOR ALL AEOUIKm INSPECTIONS AT MOST 400 S 2S. COMPLETE DRALMNIO AT LOWER AWA PROVIDED. <br /> mBn.J X CALIFORNIA�7w q5 22L-} •r6,q 6,.d... Abson Tm. C,PT Opem}icT,s fr1AAa o D,t, I I-1y-4b <br /> I •y IS01 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR NOUN PLOT PAN ffk v to$coal S.o o <br /> MHO THE FROPRTY, <br /> 2. OVTUNE OF THE PROPERTY,OIVM DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF All EXISTNO AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AM WALXB. B. LOCATMN OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOWINO POKFrFy. <br /> Ci <br /> ® ` <br /> ` ® W100 s® <br /> ,dC,P,T-100 M W 10 <br /> eq MW101 1 <br /> cow14 <br /> \ CHMW-5 MWI1 ®5-4 3 2 <br /> C 10 a <br /> H <br /> C \ CH W- <br /> `Ga Statin CHMW-3 <br /> 8 s <br /> 2 W3 1 \ pAC1Fic AVEC <br /> 13 CHMW-7 CHMW-6 / �L= <br /> O 150 FEET <br /> Station / <br /> 14 (\ <br /> ...... <br /> DmMTMFNT Vol ONLY / <br /> Doll Zf• ( S� .G (/ I <br /> OroVt MRp..tl.n Br 0.1. R P In.P.al.n Sr Got. <br /> DatMlbn In.P.atb Br <br /> not. <br /> Cemnrerx.: 'i <br /> ACCOUNTING ONLY: AIDI FAC# <br /> FE CODE{ FEEING AMOUNT RFAIITTED CHECK/MA{N RECEIVED[Y DAT[ <br /> INRMITR{BMCE REOUF°T NUMBER INVOICE <br /> Pub.Health Sew.-Enviro.173(3/96) <br />