Laserfiche WebLink
APPLICATION FOR WELL/PUMP PERMIT <br /> ' SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION, <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON REFDIIDABLE PEgMIT EXPIRf4 7 YEAR FROM DATE ISSUED �� <br /> ICompl/t/In TripRatil ti <br /> AN <br />+ A 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERWCEB,ENVIRONMENTAL HEALTH DIVISION, <br /> APPLICATION 18 HERE BY MADE 70 THE 6C1N QAOUtN COUNrY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOPrC DESCRIBED.THIS APPLICATION 1 MAT1 IN COIGN, J�QIt S <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, - CI p� PARCEL 812 APN/ I ]`t// <br /> r?D,2/ �S1TECoDE�a37 crry PHONE x o 6�D2 6 <br /> JOB ADDRESt;MR APHI ppp}TE/i u, ,fix 2a� - <br /> _76 <br /> ORr D�$7GC .� oral LNCI�—PHONE /6 <br /> OWMPIEi{'S NAME t r/� J r] ADDRESS I <br />.�� wG sr 3'��I.�r n`f►R �a l''f A �n �1 f �R �PHONE E•�.�� <br /> fk, �,TT - I U{, � �.4 d(A� 1Xe 116ORE1t8 <br /> ts�CONTRACTOR r ,� — a t' .. .. <br />(� _ Iq� ❑ OTHEfl f <br /> ❑ REFtACEMENT WELL w p1 MONITORING WELL Ir ❑ VAPOR EXTRACTION WEU/ <br /> TY Q MW ❑ NEW WELL " <br /> Q ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CFW99-CONNECT REPAIR. FIRST WATER LEVEL— 8 <br /> DEPTH PUMP SET FT. .. <br /> ❑New 0 Repent H.P. ;M.... I <br /> ° ,I"^ ❑ SOIL BORING <br /> tHYPE <br /> OF <br /> PUMP! $ ❑ Ovr-0E-SERVICE WELLf ❑ GEOPHYSICAL WELL r�� <br /> ak <br /> ❑LTEBTRVCTION: "' ` - <br /> INTENDEy USE TOPE OF WE1. CONiTRUCTION SPECIFICATION! •1�'ee' '; <br /> E A <br /> e ❑ <br /> INDUSTRIAL USE <br /> ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONDILA•OFCONfJUCTOR CA.. O d <br /> �( 'TYPE OF CASINOBTEEIRVCD1A.OF WELL CASINO U <br /> ❑ WMESTICMMVATE C9ORIIVELPACKISIZE� <br /> .DEPTH OF GROITT SERI c. FICATION <br /> ❑ PUBLICJMUNICtPAL ' ❑DRIVEN . .s O ,,,,ld <br /> ❑ rmbATIONIAG ❑OTHER oROTfF SEAL INSTALLED BY r�TiRd BRAND NAME �4 tp, f <br /> MONITOPoNG GROUT BEAL PUMPED: ❑Yr f-"'I'1e ONCRETE PEDESTAL BY DIgILER:/71 Ye■ CJ Ne S <br /> APPROX.bEPTH /L C T,{ LOCKING CHESTER BOXISFOVE P1Ff�,�^ S <br /> ► .' <br />{ PRQTO/ED CON/TRVCTtONIDRRLIONQ MEFO1Ov: MUD ROTARY AIR FTOTARY AUGER _CABLE OTHEq <br /> I HE9E9Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUDL COUNTY. HOME OWNER OR OCtENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERTOIt1u1ANCE OF TIIE WORK FOR WHICH <br /> T/A9 PERMIT to IS8lOE0,I SHALL NO PLOY PERSONS SUBJECT TO WORKMAN'S'COMPEII/ATION LAWS OF CALIFORNIA CONTRACTOR'S HIRING OR BU"ONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: -ICE RT T THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT,19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOIAAN'B CDMPEN/ATION LAWS OF <br /> CALIFORNIA.' CALL 2i HOUR/IN ADVANCE FOR ALL <br /> I�REQUMED MSMTION/AT"14pJH2l. COMPWt DRAWING AT LOWER AREA PROVIDED. g <br /> — Btirrd x <br /> Date r f L <br /> ut ` <br /> �'4�LOT PLAN nkaw to Bo■,e1 goat. 'to � :p �I <br /> 1. NAMES OF STREETS D ROAD8 NEAREST TO OR BOUNDING THE PROPERTY• 4. LOCATION OF HOUSE SEWASE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PI ,O1VUq OIMENSIONS AND NORTH DIRECTION. .e EXPANSION OF SEWAGE DISPOSAL SYSTEM/. f <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTBIO AND PROPOSED I; /.LOCATION OF WELLS WrTNINAADRJS OF ONE.HUNDRE�FIFTY-F7- <br /> STRMTUREB,INCLUDING:COVERED AREAS SUCH AS fATIOS,_DrSVE1NAV8, ON THE'PROPERTY OR'11OJORBH6 Vt1OP'EITTY <br /> r <br /> r " Ij4,3EL�1/LL <br /> 4v: <br /> . <br /> t T <br /> 7 R <br /> .., ,� <br /> A. <br /> : .. - � <br /> -,DEPARTMENT USE QNLY <br /> Appllenlen Aeeapted or <br /> / # b■H <br /> i G1OV1 Irnpeetlen III veto _ �[( ; p lmpeetlon By Dots <br /> O"Inmilen Impectlon ev Date <br /> ACCOUNTING ONLY: AID/ FACT <br /> / I <br /> PE Cotm FEE INFO AMOUNT REMITTLD16.7- 11 RECEIVED BY DATE PLTVNITISERVICE REQUEST NUMBER INVOICE' <br /> .37 (p C-z 5-tN r 9 <br /> y� f <br /> Pub Heath Serv.-ErnirD.173(1197) 7 <br /> G4 �-f <br />