Laserfiche WebLink
%APPLICATION FOR 11VELLIPUMP PERMIT <br /> 8 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR fROM DATE 1111 <br /> IC6mpbts ME Ulplb3tE) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE W COMPLIANCE WITH SM <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0.1115.3 ANO,7111E BTANDAROB OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. -� <br /> JOB ApaftEBBrofl APN`r a C�)1 ��'�C�--I �\\I,5 _CITY <br /> 1 PARCEL GIZEIAPN/ <br /> OWNER'S NAME t` 1 \ -T�hc.y } AD011E66 S, tom- ` PHONE r 1`S; -Z—A.2 <br /> CONTRACTOR— <br /> CONTRACTOR_ 'I-Cr{�� �.L,�. � ADORE BB( LIC/ PHONE/ <br /> SUB CONTRAC70 ADDRESS LKr PHONE r <br /> TYPE OF WEWrVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONIT OWNG WELL I ❑ OTHER <br /> ❑ INSTALLATION Cl WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r <br /> ❑Now❑Ropdr M.P. DEPTH PU IAP BET FT. ���...FIIRST WATE14 LEVEL c <br /> rrYPE OF PUMP) SOIL BO S <br /> ❑ OUT4FSERVICE WELL ❑ GEOR'fiV BIC AL WELL• <br /> Cl DESTRUCTION: <br /> INTFNp Vr W CO N3TAUC TION SP IF4CA A <br /> INA.OF WELL EXCAVATION DIA.OF CONDUCT 011 CASINO D <br /> El INDUSTRIAL ❑OPEN BOTTOM <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEEUPV/C l_-.V DIA.OF WELL AS" RI <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN G� (� DEPTHOFGROUT SEAL L_t�v��\�l`11�.c�"�-� SPECIFICAT N (� p <br /> ❑ IRRIGATIONIA0 YHEfl X�`-'Y`/� I I�--t. GROUT SEAL INSTALLED SY' �6 ``Z..� O NAME I D CIO e \Q,n f <br /> ,MONITORING \l GROUT SEAL PUMPED:oY ❑No CONC E PEDESTAL BY DRILLER:'Y. ❑Ne S <br /> AFRAID%.DEPTH A D' LOCKING CHEQTE BOx/SfGi�}1Pf S <br /> PIIOPOSW CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER \ OTHER <br /> I HE-%BY CERTIFY THAT 1 HAVE PREPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN JOA(XAN COUNTY ORFHNANCE6,STATE LAWS,AND RULES AN <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'll SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC <br /> THIS PERMIT 161SGUE0,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFWISATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WOR#pvRAN'S OMIENBATTON LAWS 0 <br /> CALIFORNIA.' T APPLICANT MUST CA11 2 HOURS IN ADVANCE FOR ALL REGUIRRiD)MOM TIONS AT 12001 440-3423. COMPLETE DRAWINO AT LOWER AREA VIDED. <br /> 61prW x <br /> IL Title- <br /> PLOT PLAN IOtnw to Gosh)Book 'to � <br /> t. NAMES OF STREETS OR RDAD6 NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROP06ED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION of WEUA WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A$PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> DEPARTMENT U6E ONLY <br /> Applloralon Aoo#pt�d By D.to Are@ <br /> Grout Irvpoollon By Date-- Pump I-9-tion By Date <br /> Dmtruotlon Impaction BY Dote <br /> Comments: <br /> ACCOUNTINO ONLY: AIUr FAC# <br /> PE CODES FEE INFO AMOUNT RMUTTED CHEC"tCASM RECEIVED EY DATE PERMITAYNICE REOUFAT NUMBER INVOICE <br />