Laserfiche WebLink
4 S <br /> � +� aI-•.mss f{ mf i, r, $ Sl �+.T� <br /> APPLICATION FOR WELLIPUMP PERMIT h <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 2 0 1999 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA(209) 468-3420 r H��;I 1 RISM <br /> A <br /> ROI[REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED V L <br /> Kk"ir'la IIT Trlpliealel <br /> APPLICATION 18 HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOR(DESCRIBED TWO APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> I JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9 11 IS 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOBADDRESSIOR APN# 5 / CITY ,/ y ��� _� PARCEL SIZEIAPN/ <br /> �(/ <br /> ap <br /> OWNER 8 NAME a 6yI ¢lr ADDRESS 7J1G1� I�►� l �, L� Xr-1 SNE 0 <br /> „ff// <br /> CONTRACTOR J(/1 �(J ✓IyYI _ ADfk1E88T�/ W -- LIC/ PHONE E' 7�— <br /> Bus CONTRACTOR L1CZZ&�zR PHONE �6 Z <br /> TYPE OF WELIJPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO86CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J <br /> ❑ <br /> N.❑ro..Y H P DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> (TYPE OF PUMPI <br /> ❑ DVT-OF-SERVICE WELL ❑ OEOPNYBICAi WELL.I ROIL BOT1tH6 � g <br /> ❑DESTRUCTION <br /> INTENDED USE TYPE DPW” CONSTRUCTLON iPECIFICA IONS A <br />' ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION !// „ DIA OF CONDUCTOR CASINO (7 <br /> ❑ DOMESTICIPAIVATE IV <br /> ❑GRAVEL PACBRE TYPE OF CA9tNOlSTEELIPVG vV GIA OF WELL CASINO^ Z�� O <br /> ❑ PIBLICIMUNEICIPAL ❑ORIVEN DEPTH OF GROUT SEAL �sS� /O SPECIFICATION 6� _ R <br /> ❑ IRWGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY_TiY��sM/moi_ GROUT BRAND NAME /O/7CC11I_� E <br />' JKMONITORINGr I / GROUT SEAL PIMPED ❑YXINY. 151 Ne CONCRETE PEDESTAL BY DRILLER ❑Y« ❑Nn S <br /> APPROX DEPTHI LOCG CHESTER SOXJSTOVE PIPE S <br /> PROPOSED CONSTRl1CT10NfORIWNO TNETHDp MUD ROTARY AIR ROTARY AUGER��CABLE OTHER <br />'Aak <br /> gEBY CERTIFY THAT I I4AVE PREPARED t1418 APPIJCATION AND THAT THE WORK WILL IDE DONE IN ACCORI7ANCE WITH BAN JOAOUIN COUNTY OROWANCE9 STATE LAWS ANO RULES ANt(,Z:5 <br /> -FIEQUtATIONS OF THE BAN JOAQUIN COUNTY HOME OWNED[OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING 1 CEFTTFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED 1 814ALL NOT EMPLOY PERSONS OUBJECT TO WORLWIAN B COMPEMISATRON LAW$OF CALIFORNIA- CONTRACTOR B HIRING OR SUBCONTRACTWO SIGNATURE CERTIFIES C <br /> THE FOLLOWING '1 CERTIFY THAT IN 711E PERFORMANCE OF THE WORK FOR WHICH THIS PEMArr 18 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORNMMAM S COMPINSATIOTI LAWS OF <br />' CALIFORNIA,' T CALL 24 NO IN ADVAMICE FOR ALL REQUIRED INSPECTIONS AT T20a1 44SJ422 COMPLETE DRAWING AT LOWER AREA 91PRIONVIIDED <br /> gn.d% <br /> PLOT PLAN Wk.is 50•I.1 8e•I. 'to <br />' ! NAMES OF STREETS OR ROADS NEAREST T M.UINWM THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DLBPOSAL SYSTEM OR PROPOSED <br /> 2 OVTLINE OF THE PROPERTY GtV*M OVAENeIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS <br /> DIMENSIONED OUTLINFS MSO LOCATION OF ALL EXISTWM AND PROPOSED S LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> STRUCTURES INCLUMNG COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALK$ ON THE PROPERTY OR ADJOINING PROPERTY <br /> URI � <br /> 1 <br /> V "T <br /> 1 1 <br /> DI PARTMENT USE ONLY <br />' APPse•tien Ae~od BY DN. S-Z _ • A,« ��S A <br /> G.-A ln..a.11.n By O.t• PImP In.paetlen By D•1. <br /> ON. <br />' De.ln�cll.n Er..lr��aclls��n By TTJ���f ' ''t y <br />' ACI:OUNTIHG ONLY AID# FAC# <br /> yE COPES FEE INFO AMOUNT RIDWTTED CHECX#ICASH RECEIVED SY DATE !@IIMtTfi[AVICE REGVEST NUIVIS RAI INVOICE <br />' 3`JO Z= S <br />