Laserfiche WebLink
APPLICATION FOR WELUPUMP PERMIT ° <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAR 15 1999 ENVIRONMENTAL HEALTH DIVISION mP,P. j p 1999 <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> I[RR•REFUNDARRE FERIMIT EXPIRE=-1 YEAR FRRN RATE ISSUER <br /> 1GwIFNh M 71IFRa1Ml <br /> APPLICAMN M I4ERE By MADE TO THE SAN JOAOVIN COUNTY FOR A PEMW TO CONSTRUCT AMMM INSTALL THE WORK OEBCIM■EO.TME APPLICATION is MADE N COMPLIANCE WfTI(SAN <br /> JOAOUN COLWtY OFMOPMENT MLS.SCHAPTER 09.1 115.3 ANDTHE ETANDAMI OF EAN JOAOVIN COUNTY Pllf■LIC HEIA�LTH SERVICES.EHVIRONMEIRAL HEATH DINE?ION. <br /> ORE <br /> JOB AOBSA7R AM, I� - Y A 1/ r R 1'1 7 D �i cITY ! (<16 v T PARCEL 912E/Alar ! <br /> OWNER'rNAME a'; ADDRESS 3_N13 [W.`�7aFck Lg.a S�7"A 12.o ry+D+IEr117L3!~BSdD <br /> ItCONTRACTOR V 4 wi{f 1�j_�0 y�-VI �^_ �l 1M T{+i Q (T 11 c_ AIO IEEE_ 100 7 fV 1+1�,'�SO it W Z C,90 17�-1 �Iy,IOwL,`1y6 7(`10116 <br /> am CONTRACTOR N i re'1 £ I r A f i I0 14� - ^ADDHESS u.,r rz, [ f PHOp9E r 1�V~46 9 o <br /> TMP!OF WEITJPUMP. ❑ NEW WELL ❑ rwm ACEmm wEu ❑ MOMTORN4 WELL• 41 OTHERSid�%'fAg W1F r 1 <br /> 11 NSTALLATKI N 11 WELL SYSTEM REPAIR 11CROSSiONNECT REPAOI VAPOR EXTRACTNON WELL r J <br /> ❑NN.Q R.P.k H.P. DEPTH PUMP wr FT. FIRST WATER LEVEL 1 5'/ a <br /> (TYPE OF PUMM <br /> ❑ OUT43F-SERVICE WELL ❑ OEOMYEICAL WELL r ❑ BOIL Gomm R <br /> ❑DEBTRUCTIOR: <br /> N M <br /> CONSTRMIMM EPEC A N r I A <br /> ❑ TNDUETRIAL D OPEN bDTToM DIA.OF WELL EXCAVATION p� FAA.OF CONDUCTOR CASINO y o <br /> ❑ DOMEEMAWVATE r®71 GRAVEL PACIlE17E;3 IV OF CA MISTEEUPVC ! �' _ DIA_OF Witt CASING <br /> ❑ FtMJC MIMNCPA W GRAVEN OEPTH OF oFwM SEA 7 SPECIFICATION Sc. g Cs R <br /> ❑ IRMSGATIONIAG ❑OTHER GROUT SMN.*NMT IIL.LED ZY J a GROM■LUNO HANE b} Q�� E <br /> ® Mowomm Q N - GROUT EEA PRMAPEO: 12 Yr ❑N. CONCRETE PEDE<TAL■Y Omwm,❑Yr IAN. s <br /> APPROx.DePTN_ 3-p LOCKING CHESTER■OXMFOVE PIPE, s <br /> PROPOII®CONSTR WHONRXWMI6 METHOD; MRO ROTARY ,AIR ROTARY AUOER_4 CAKE OTHER <br /> 1 fERE■Y CERTIFY THAT 1 HAVE FIEPAIEO THIS APPLICATION AND THAT THE WORE WILL EE DONE N ACCORDANCE WITH SAN JOAO"COURTY ORE NANCEE.RATE LAWS,AND RULES AND <br /> REOULATIOINE OP THE BAN JOAOUIN COUNTY. HOW OWNER OR Ll"NSED AOEHT'S VONATLSE CENTFlS THE MLLOWING:'1 CERTIFY TNAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMMF NI HBUED,I NTMI HOT EMPLOY PERSONIB■NWECT TO WOW(MAN'S COMPONSATION LAWS OF CAUFORMA.' CONTRACTOR'S WWW OR KGS-CONTRACTMG IMMATURE CERt*wS <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PEYFORMJANCE OF THE WONK PON WHICH THE PERMIT IB I0SUH4,1 SHALL EMPLOY FERSOHS KMJECT TO WORIOMAWS COMPENSATION LAWS OF <br /> CALIFOIMM.' TIME APPUCMn IAUSTT CALL 24 NOMM IM AAVMICS FOR ALL F&IMMID INWWTIONS AT 1=191"44111AD477. COMPLETE DRAIMNIO AT LOWER MEA NOVIDEO. <br /> alp X_N , nn. 501 o`B I- 61 B ff G le 1<i 4 7' <br /> PLOT PLAN Id.w N SoA.I Sad. •I. <br /> 1. NAMES OF RE <br /> STETS OR ROADS NEATEST TO OR SOUNDING THE FROPEATY. 4. LOCATION OF HOUSE SEWAGE SAL SYSTEM OR PROMIR[D <br /> 2. OUTLINE OF TIRE/RIOP£IITY,GfVM DOM 4NONS AND NORTH Oft TOH. EXPANSION OF SEWAGE DISPOSAL SYSTEM■. <br /> 7. D MENENMW OUrLR4F4 AND LOCATION OF ALL EXIBTNO AND PROPOSED S. LOCATION OF WELLS WITION RADIUS OF ONE MR40WO FIFTY FT_ <br /> STRICTURE■,11 CLUDMNG COVERED MEAS @MR AS PATIOS.DRIVEWAY■,AND WALKS. ON THE PROPERTY OR ADJOOMM PPOFERTII. <br /> ve P4 <br /> i W <br /> _ff DEPARTMENT LIE*ONLY _ <br /> A.R-A@wW@d■Y � ^` f r <br /> D <br /> Omit I,,.ga4lm BY, D.I. <br /> b.NaeMn , j <br /> bmt. r �� <br /> 4 ! 5 �'v7T71Yr_ <br /> Yl c 'L a f l�' ►� ti�� S v . <br /> "COu4TWOONLY: AMOF FACT <br /> PS CODES FEE INFO AMOUNT NENSTTM CHECKIICASH RECMV■ DATE Po"WNERVICE REOLSYT NISN■ER INVOICE <br /> 00 S 9U'Vo 00 <br /> SCK 00 � � bao <br /> Pub HeaMh Serv.-ErMro. 173(1197) <br />