Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION AUG 2 4 7999 <br /> 304 EASTIWEBER AVENUE,-STOCKTON, CA 95202 <br /> (209) 46$'3420 =jri'`1'i-Po <br /> ?:�iy`i '3 f, ! s-,1. r <br /> . .�,L-! H <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> '� {Camphu In T►fI111e�1F) ' <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCMEZ0.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-.1 11 5.3 AND THE STANDARDS OF BAN JOADUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADOREBSMA APNI V C-11-:S1124'VO" \ PARCEL SIZFJAPf4# (��j {� <br /> r- A'S NAME I-1 5 � \0. :Lf ku�, ADORE -�•,3 1 . .. -. �- PHONE• / r 3 l� d <br /> CONTRACTOR ^T�.I 'ILLLA.Y��^, SGL S�C-�hrtC' .,_��i lln Vj ktlhiAODRE88 f I 1�Q a S' C ") UC/ PHONE/ . <br /> sun CONTRACTOR-\LI`-�1Ul ((��Q-O ��Ill�, r ?, ^] ' +�^� 7 <br /> -1"., ADDRESS f��X / �l! LICE PHONE.3ritS �(�.�7 <br /> TYFT OF WELUrUMP: ❑ NEW WELL ❑ REPLACEMENT rWELL 'r ❑ MONRORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑Rapalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> (TYPE OF FV MPI <br /> 13OUT-0F•BERVICE WELL ❑ GEOPHYSICAL WE[1,/ Ia SOIL BORING <br /> ❑DESTRUCTION! ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ©OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTIC/MVATE ❑GRAVEL PACI(/SIZE TYPE OF CASINOISTEELIPVC 01A,OF WELL CASINO p <br /> ❑ PUBUCMA INICS'AL ❑DRIVEN DEPTH OF GROUT SEAL BPECITICATION R <br /> ❑ IRRIOATION/AO ❑OTHER GROUT SEAL METALLED BY GROUT BRAND NAME <br /> NITORING * .GROUT SEAL PUMPED: ❑Ye. - f <br /> ❑ MO <br /> ❑Na CONCRETE PEDESTAL BY DRILLER;❑Yea ❑Ne S <br /> APPROX.OFPTH �Z�S � LOCKING CHESTER BOX/STOVE PIPE <br /> 1 S <br /> PROPOSED CONSTRUCTIORMI ILLINO METHOD- MUD ROTARY AIR ROTARY AUGER 7C CABLE OTHER <br /> b, <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORI(WILL BE DONE MI ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISS . SHA NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR•8 HIRING OR SVBtONTRACTMIG SIGNATURE CERTIFIES <br /> THE FOU OWI I C RTTHA IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CQMMSATTON LAWS OF <br /> CAUFOF" HE CA 24 NOURS IN ADVANCE FOR ALL REOUIRM INSPECMPIS AT IMS)4844422. COMPLETE DRAWING AT LOWER AREA PROVIDED. ♦ � <br /> 04r-d Title bne <br /> }LOT PLAN(Draw le BcAel Beala�''to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVM/G OIMEMBIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE 1348POSAL SYSTEMS, r <br /> 2. DIMENSIONED OVFLMF.B AND LOCATION OF ALL EXISTING AND PROPOSEO S. LOCATION OF WELLS WrtMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUOINO COVERED ARF,AB SUCH AS PATIOS.DRVEWAYe,AND WALK8. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> gj�!u.1t rbY11/YI.C,rh7'�A,� <br /> DEPARTMENT USE ONLY <br /> APPOWIbn Aceep,ed By At <br /> �3n Dole`_ <br /> Oravl lmpeeller.By �/ � Date pie Inanseelon By <br /> Date <br /> De.InletMn tmpaetlen By <br /> Oste <br /> I� <br /> ACCOVNfINQ ONLY; AIDE II FACT <br /> PE CODES FEE INFO AMOUNT REMITTED EC J ASH RECEIVED BY DATE <br /> PWMIT/SERVICE REGUEsT NUMmeR INVOICE <br /> Pub Health Serv.-Enviro.173(1/97) �� <br />