Laserfiche WebLink
. APPLICATION FOR VVELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVII. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (2091408-3420 <br /> NON•REFUNDA611 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (compbtl II TlipBwtl) <br /> APPLICATION IS MEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICAT ION 18 MADE IN COMPLIANCE WITH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CIT4APTER 0-1115.3 AND,THE STANDARDS Of BAN AJOAINCOUNTYPUBLUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOS ADORlEBB/OR APNIPARCEL 61ZE/APN/ ;����'0OWNER'S NAME �t'� t�, AGGC4(�) 5.�fib- PHONE I <br /> �^ 1 LIC/ PHONE I <br /> CONTRACTOR it �A� t-�J \C•`^ `^^`2`;\. ADRAESS c <br /> But CONTRACTOR <br /> AE)dREBe _ txs 2( G PHONE <br /> TYPE OF WEtuf'k)MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> [IINSTALLATION C] WELL SYSTEM REPAIR/ ROSS-CONNECT REPAM ❑ VAPOR EXTRACTION WELL i <br /> ❑N. f4p.lr M.P. (� DEPTH PUMP SET �CIIOIL <br /> FIIRST WATER LEVEL E <br /> RYPE OF PUMPS BORING B <br /> ❑ <br /> OUT-OF-SERVICE WELL ❑ OEO BIC AL WELL I <br /> I <br /> ❑DESTRUCTION: <br /> INTEND UD Agi CONSIRI T10N SPECIFIC TIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM ENA.OF WELL EXCAVATION �,/II DIA.OF CONDUCTOR CASING D <br /> ❑ WMESTIC/PRIVATE ❑GRAVEL PACK/SIZE Of CASING *EEIJPVC V�/' DIA.OF WELL CASINO 0 <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN + DE _0f UT SEAL C Y"n Y\V,LA-C' '�-5 SPECIFICATION R <br /> ❑ IRRIOATIONIAGOTHER .;��671 �Cq � 6ROlIT SEAR INBTAUED BY �6�\ \k�-� 01gUT BRAND NAMED G b YV�e,�l E <br /> MONITORINO J \ GROUT BEAL PUMPED:10Y. ❑No CONCRETE PEDESTAL SY DFYLLER:Jp VM ON- S <br /> APPRIOX.DEPTH �L�' \ LOCKING CHESTER BOXAVf0k+'PI% S <br /> PROPOSED CONSTRUCTIuNfMLUNO METHOD: MUD ROTARY \' AIR ROTARY___ AUGER_CABLE OTHER. <br /> I HENEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WItL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORMNANCEB,STATE LAWS,AND RULES AN <br /> t¢uULA-.;uN2 c:6 TILE SAN J.^.ACJIN COUNTY. momf OWNER OR LICENSE AGENT'S SIGNATURE CERTIFIES THE FOLLOWNO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC <br /> THUS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOR AN'i COMPENSATION LAWS Of CALIFORNIA.- C0NTRAC7UR'S Hi1iN0 On FL;" NTA,X^-i:'IG Z:W,IATUR-CFRT:9lE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE I R WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOR10uIAN'S COMPtNSATHIN LAWS 0 <br /> CALIFORNIA.' T APPLICANT MUST CALL 2#HHOLALI IN ADVANCE FOR ALL REOLIMtED INSIfCTTON*AT 1"011-4"-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> TItls D.. <br /> BRUT.d x <br /> PLAT PLAN IDF"to 504111 8"4 'Io <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OF,BOUNDING THE PROPERTY. 4. ROGATION Of HOUSE SEWAGE CNSPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fl. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS- ON TME PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USK ONLY <br /> Mw <br /> Appllo.lbn Aop.pt.d By <br /> GIaUI Irvpootlon BY D.to Pump In.p.all Dao <br /> pwitruollon h—poallon By t7ot. <br /> Comm.nl.: <br /> ACCOUNTING ONLY: AIDS FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECOVED BY DATE ►BI"TlIBRVICi"GOU"T NLMBEf1 INVOICK <br /> �cj cl r 0 32 ( 8 , ( C <br /> c <br />