Laserfiche WebLink
n APPLICATION FOR WELL/PUMP PERMIY- <br /> q15'73 <br /> SAtAQUIN COUNTY PUBLIC HEALTH SEICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompMts In TripIket.) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANGIOS INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. - <br /> JOB ADDRESS/OR APH/ � CITY ' y PARCEL 81ZEIAPNI <br /> OWNER'S NAME �`Qr ADDRESS <br /> CONTRACTOR ADORE as ZA 'C' PHONE <br /> OM ADDRESS LIC/ PHONE 1 <br /> TYPE OF.WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER <br /> (3 INSTALLATION ❑WELL YSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J r <br /> -� ! LEVEL-4 <br /> New❑Repelr M.P. � L DEPTH PUMP SET�Fr, FIRST WATER <br /> rtYPE OF PUMP) <br /> ❑OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL n © SOIL BORING p <br /> DEBT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 111 <br /> -❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ODOMESTIC/PRVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEtJPVC DIA,OF WELL CASINO p 1) <br /> ❑ PUBUC/MUNICIPAL_ ❑DRIVEN DEPTH OF GROUT SEAL SiECIFICATION p -31 <br /> © IRMATON/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ,E I <br /> © MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑YeaRS <br /> ❑Ne <br /> \ <br /> ' <br /> APPROX.DEFPH LOCKING CHESTER BOXlBTOVE <br /> PE S <br /> PROPOSED CONITRUCTIONR7WLUNO METHOD: MUD ROTARY AIR ROTARY AVOER CABLE OTHER <br /> I M"EBY CERTIFY THAT 1 HAVE PREPARED THIR AlPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAOUIN 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 18 ISSUED,1611ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOIL O: *At CERTIFY THAT INT E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT BS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN3 C MPQI6ATION LAWS OF <br /> CAUFO IA.' APPLICANT MV87 A Z4 HOUR/IN ADVANCE FOR ALL REOt11RED 1 BPECTION6 AT 1"61 486-2413. COMPLETE DRAWING AT LOWER ARE PRO ED. <br /> SIQr,ed% Tllle ED' <br /> O.ta <br /> PLOT PLAN(Drew to Seale]Scale •to <br /> P. NAMES69FT8 OR ROADS NEAREST TO OR BOVNMNO THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PMrOSED <br /> i. OUTLINPROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINF.6 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOtNMO PROPERTY, <br /> ... ... G� . <br /> :.... .. . ....... . <br /> . ..:......: <br /> Q <br /> .. ..:...... <br /> :.. .:: <br /> ......:.... <br /> ... <br /> r-i - ANT. ..... <br /> :...............: :.. <br /> 19:7 <br /> u <br /> : .. <br /> - - <br /> ' SAN JOA INUfv <br /> COTX <br /> r y.� DEPARTMENT USE ONLY EN}�)RONMENTAL HESL.TH DIVI I <br /> UM <br /> I � 1 <br />