Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O,BOX 988,304 EAST WEEIER AVENUE,STOCKTON,CA 95201398 <br /> (209)489.3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICIIInpIRtB IR TrolkRtR1 <br /> APPLICATION IS HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT 10 CONRTRUCT ANDMIN INSTALL THE WORK DESCRIBED.TATS APPLICA LION IB MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNtY DEVELOPMENT TITLE,CHAPTER O-1116.3 AND THE STANDARDS OF RAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,FNVIRONMENTAL HEALTH OIVIBICN, <br /> JOB AODISBSAOII APR/ p 0 <br /> ,I�1� n e,n _fT� �, PARCEL SIZEJAPN/_ <br /> UVMFR'B NAME_, F 1 r <br /> 1s�i 11 r G r r AODRFRR {J,1L�/��{�� 1 y <br /> CONIRACTOR��L-I !TA_S IE le L, _Tn 0_, ADnAF96f�I b,f4h fri LNC/� PHONE/83s <br /> PUB CONTRACTOR ADLMiFSB ryr <br /> TYPE OF WEUJPLIMP: ❑NEW WELLi. F❑- MMACF.MEM WELL ❑MON110R�NA WEIt/ LI OTHER <br /> 1 1❑y INSTALU {, <br /> T10N J WELL SYSTEM REPAIR ❑CROBB-CONNECT REPAIR ❑ VAPOREXTRACTION WELL/ J <br /> u b LJ N—Oft—,,,,t H P,_— DEP711 PUMP BET—FT. FIRST WATER LEVEL <br /> HYPEOFPIIMR RG G <br /> ` � ❑OUT-0T-SERVICE WELL ❑OEORIYBICAI WELL! ❑ 009 BORING B <br /> ❑DESTRUCTION: <br /> O <br /> INTENDED URE YPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS A f., <br /> ❑NOUSTRIAL ❑OPEN BOTTOM IRA,OF WELL F%CAVATION CIA.OF CONDUCTOR CASINO p W <br /> MMESTIC/IYVVA7E ElMEI <br /> OV .PACKMIZEPE_ TYOF CASINGMT F.ELi VC _ DIA.OF WELL CARING V <br /> WO <br /> ❑RIRUC/MUNIMPAL (I DRIVEN DEPTH OF CRCUI SEAL -- R)TCIFICAIRON R <br /> ❑IRRIOATONtAO ❑OTHER GROUT SFAL INSTALLED RY OROUr BRAND NAME E <br /> ❑MOMrORINO GROUT BEAT.PUMPED:❑Y- ❑Na CONCRETE PEDESTAL BY OWLIFR;❑YM ❑Ne S <br /> AtNR1OX.DEFTR LOCKING CHESTER BOXISTOVE PIPE__S <br /> PROPOSED CONSTRUCTONIdSWNO METHOD: MUD ROTARY_ AIR ROTARY AUGER _CABLE OTHER_ <br /> 1 HEREBY CERTIFY THAT I HAVE RIEPAREO TMS APPLICATION ANTI THAT 11E WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAMM COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> RFOULATIONR OF THE RAN JOAQUIN CUVNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES 74E FOLLOWING:'1 CERTIFY THAT PN THE PERFORMANCE OF THE MAN.FOR V1MCH <br /> 7 HIS PERMIT 4018"D.i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORIBA.-CONTRACTOR'S NIFWO OR SUB CM$tACTINO CICNATUM CEMIFIES <br /> THE FOLLOWING; '1 CERTIFY THAT IN TIRE PERFORMANCE OF THE WOR!FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS BURIECT TO 111001"AN'S COMPI"A110N LAWS OF <br /> CALIFORNIA.- 711 APPLICANT MUST CALL <br /> 2/ ,f_1 <br /> 4 HOURSINADVANCE FOR AIL REOUREO INS" rIGNO AT f2"I 402-3423.COMPLETE DRAWING AT LOWER AREA PIIOVTOEO. <br /> Bned% i) 4[�{/L <br /> 21 -1� tl1S <br /> �1L �� Tllle i/O A Mn A <br /> Bl <br /> PLOT PIAN ID—.B.H Ra Ma 7-"s_'ile'--"` <br /> 1, NAMES OF STREETS OR R0AD8 NEAREST 10 OR BOUNDING Tt1E PRDIERTY, -_ R. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> i.OUTLINE OF TIRE PROPERTY,OIVIRI DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE INWOBAL SYSTEMS. <br /> ],DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMO AMC PROPOSED S. LOCATION OF WELLS WI7HIN RADIUS OF ONE HUNORFO FIFTY FT. <br /> STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU'.e. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i p4t'�e'rsa� P�� <br /> 0 <br /> ag <br /> 5 <br /> ghs�n U <br /> s <br /> cn 2. <br /> n <br /> "�orr�l �40)jatj <br /> DEPMTMEJIT USE ONLY <br /> APWlenlen APeepT..I BY ct�.-,-� JL ° P—p A... <br /> D.1 <br /> a.Ow I.RpeellRn BY <br /> O.rlrlrelbn <br /> 1—6..By <br /> ACCOUNT,.,ONLY: AID! FACT <br /> PE CODER TFE INTO AMOUNT RBA,TT[p CHEC AEII RECDVEO BY DATE PERMITp@IVICE 11EOUEST 11.1 R INVOICE <br /> tf <br /> 3 0 O S Q <br /> Pub.HeBllh Serv.-Emiro.173(31961 <br />