Laserfiche WebLink
�ArrY ] ! 14,96 <br /> Y APPLICATION FOR WELLIPUMP PERMIT <br /> �- SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES JAN t <br /> ENVIRONMENTAL HEALTH DIVISION �g <br /> P 0 BOX 381 446 N SAN JOAQUIN ST,STOCKTON CA 96201 388 <br /> (209)418 3420 <br /> RORREFUNDAREE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (COMP1SIA IN TF4119118) <br /> APRICATION 1.HERE W MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCPREO THIS APPLICATION 19 MARE IN COMPLIANCE MEN SAN <br /> JDAOUIN COUNTY EI"U)"HnFffTITLE CHAPTER 9 11 115 3 AND THE STANO.We OF BAN JOAOURN COUNTY MOM <br /> IIEALTH SERVICES ENVIRONMENTAL HEALTH 011e <br /> mMDAESSROA APNI.JJ�QQ VJ ELI �0 "b CITY \ERO p U5 .. PARCEL WEVAPNE" o bus-Q3 <br /> OWNER NAME RobE&T,B pew-175 AWMSE $-70 WdST a`Ilr� Pf PIOIx r(t}IsfT1 7_�(a-51}ll <br /> CONTRACTOR OLO(7 It-P, ccll�IG�� n ADDRESS glyp'_D�.� 11�%%1PJt(ZA{ 1�1 Q�S�J� hwNEE <br /> SVR CONTRACTVR �54I F{�_ _ y.I}v���F� AOOMMS Yl�T R1Y�T.�.�II C. Fo 91gNEE �s�T�'>A�f <br /> �F ry <br /> TYK OF WELIJR/MP: 1L-TJ NEW N1ELl IQ-�11FPlJICEMEM WELL iL-J1 MOrYTORHM WELL/ �❑ry OTHER <br /> I..;INSTIAFLATNIN Q WELA"STEM AEPMR ❑CROSSCONNECT REPAIR CI VAPOR EXTRACTION WELL. J <br /> ❑N-001H P DEPTH RUMP lFf_Ff FRQT WATER LEVEL O <br /> TYPE OF PIMPI <br /> C1�1 OUT OF S[1NICF WEIi ❑OEOPNYBICA WELL V Ie AO4 AORNG ALA <br /> Q DESTRUCTION <br /> INTIMDED UH TYPE OF WELL CONSTRUCTION SFECIFICATN1Ne R� A <br /> _ ❑INDUSTRIAL ❑OFEN wrrapA tlA OF WELL EXCAVATION Is DIA OF CONDUCTOR CASINO <br /> ❑WmtwIOA'RVATE Q OMVEL PAC mzv TYPE OF CASDIOUETEELMTC NN , OIA OF VVELL CANING iJ_A_ D <br /> ❑RMUC OUNICRAL ❑DRIVEN OF►TH OF GROUT MAL—LID' SPECO9CATION N Pt A <br /> ❑WMATIOWAO OWNER GMUT SEAL INSTALLED SY Gmm SRAND NAME IE---II Q�I E <br /> 13 MONITORRO <br /> PIO OUTSEALPVM ❑N.FED ®Yr CONCRETEPETKSTA$YDRILLFA.I.,IY. FM 5 <br /> -h APPwOX 0- yQ LOCNNMF CHESTER SOxIROVE RIPE 3 <br /> 1`r <br /> PROPOSED CONSTRUCROMIDMUNG METHOD MIA NOTARY AIR ROTARY AUO(R4All F^L�. CAKE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED TFEq APPLICATION AND THAT THE WORK WILL Of GONE OI ACCORDANCE <br /> WITH eAN IOAOIIN COUNTYOPpNANCfe STATE LAWS AND ES AND <br /> REOVLATN]NS OF THE SAN UDAOUIN COUNTY I OME OWNEA OR LICENSED AGENT a MONATURE CERTWE1 THE FOLLOVWID 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POLI WHICH <br /> THIS PEAMTf 10 15 ED 1 SNALL NOT EMROYPIERSOHN MUGHCT TO WOIFR/AAR■COMPENSATION LAWe OF CALIFORNIA CONTRACTOR■HMSIIO OR SUFCDNTRACTm SMNATURE CTRTIKS <br /> THE FOLLOVIMM P CERTIFY THAT IN THE FERWRMANCE OF THE 1A9FR FOR WHICH TRS PERMIT Ie ISSUED 1 MALL EMPLOY PERSONS SUBJECT TO WOMMAN i COMPENSATMIF LAWS OF <br /> CUWFOANU/�j/ry[AFF/yG.ENT MUST CALL M IN AW AMCE FOR ALL REOURfD/IM{lFSCTIOyi AT 11YM AY3Aa7t COMMMC DKA AMD AY LOWER A A FAVIOED <br /> t sITrRAx (�[. (/I.� I „- Trn. [,Kb'IGLPV1 rirrflllh/, _ ,� J wl. <br /> P[nT PIAN ew.w,.a.+H e.w 1 d , .SCJ' �• <br /> 1NAMES OF FTREET8 OA ROADS NEAREBT TO OR RDUMOMM THE PROPERTY A LOCATION OF HOUSE SEWAGE DISPOSAL SV$TEM OR RROPOSID <br /> r• 1 OUTLINE OF THE PROPERTY OMMO DIMENSION$AND NORTH DIRECTION EXPANSION Of SEWAGE MMOSAL SYSTEMS <br /> 3 DUEMMMED OUTUNES AMD LOCATION OF ALL EU IWT AND M%DM3EEO S LOCATION OF WELLS WITHIN AAORUS OF ONE HVNUIKO HRY R <br /> STRUCTURES INCLUDING COVEPAO AREAS SUCH AS PATIOS W VEWAYS ANO WALKS ON THE PROPERTY OR AOJOIHING PROPERTY <br /> onl <br /> 1CL.IATIaA ToR pl[� <br /> C' R1•Vi 9,V � / <br /> It G)ih Wn`( 3 3 <br /> �SoLr+�lEttrl PAa.+�l�Q-TSF.... <br /> A. DEPARTMENT WE GNLY <br /> AFPNF.,I.n AA[y[tl eY !1A- J�7N'17OA/ <br /> D..,A MRwrHn EY On. I\.RF I.�.slls,R D.,. J1Si('1�AV L/~� <br /> Ont <br /> ACCOUNTfN1 OMY ATOP Y FAC. N O' <br /> FE COOU FAS IMFO AMOUNT REMEITED CHECUXAFH RECDVED By "TE MI R ITMEPPA.E­PAT Nl.AR9r tMV ICS <br /> U CI� Sz K bGS !D C71C� 2 <br /> N Uc E <br /> Intl', <br /> r� <br /> _L., a <br />