Laserfiche WebLink
APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JUN 2 2 1998 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cempltt@ IS Tripiktttl <br /> APPLICATION IR HER BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELO'PPM1EENNTTITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PIBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. �/1 <br /> JOB ADDRBS,OR APNI 1`(J VIE$I VOSQ VY �-L CITY/1 A) A iy 7cF C A- PARCEL SIZVAMF: <br /> OWNER'S NAME Phil <br /> `h i l ENS ADDRESS 7 La 0 217- /1.�.'15Q N11I-E mom I, <br /> CONTRACTOR AVD CFI) Ge(1 CRVI/'D E/1T0 -4lC AODM99YDD5 AI. I\II/S�l1 W(Jy UC/b$OZZ�PNONE/ 209-967-/oOfp <br /> RUB CONTRACTOR \1 // \♦ t/ AW'Re8 \1 ♦ ` ' I IlC/ MORE/11 N/ \♦ 1/ <br /> TYPE OF WEUMUMP ❑ WAf WEM ❑ REMCFMENT WELL ❑ MONRONNO WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ <br /> ❑Naw❑Rrall N.P. DEPTH PUMP Off-FT. FIRST WATER LEVEL O <br /> BYTE OF PUMP) y/1❑ /f OVf-0E-SERVICE WELL ❑ GEOPHYSICAL WELL# 1�601L BORING B <br /> ❑DWnUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION aPECIFICAT10Nt A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EJKCAVATIONZlIAI DIA.OF CONDUCTOR CARING AI/T O <br /> 11DOMESTICRROVATE ❑GRAVEL PACKMIZE TYPE OF CASINORTEFIA^%i _31 <br /> C N@"I DIA.OF WELL CASINO Iv <br /> A O <br /> ❑ RIBLCIMUNCIPAL 11RI <br /> DRIVEN DEPTH OF GROUT BEAI_I_fl Dk PT+ MTIO <br /> 4CIFICAN N R <br /> A❑�INOOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY :LIp8"C N/I I F9" /I,E GROW RRANO NAME TILS iO E <br /> ISI MONRONND A� ( ONRR SEAL PIMPED: ❑Yr W. CONCRETE PEDESTAL BY DRILLER:y8 Yr ❑Ne 5 <br /> ,APPPPROX.DMH lL ` �C LOCKING CHEBFER BOX/STOVE PRE-Wf -\ 5 <br /> PNOPOEED CONtmARWROTARY TTNARINO METHOD: MUD ROTARY AIR AUGER CABLE OT F AQ cc <br /> I HEAEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WALL BE DONE A ACCORDANCE WITH SAN"AWN COUNTY ORDINANCES.STATE LAWS,AND RALES AND <br /> REOUMTIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT H THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS MANOR IS ISSUED,I SHAM NOT EMPLOY PERSONS"ACT TO WORIDMAN't COMPENSAMN LAWS OF CAUFOINHA.- CONTRACTOR'S MOVING OR BURLONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO W0111 M'S COMPENSATION LAWS OF <br /> CALIFORNIA <br /> Af' THE APPLICANT MUST CAM E4 HOW IN ADVANCE FOR ALL RFOUMED INSFKI <br /> ECTNS AT ItOtl 400J ". COMPLETERE <br /> DRAWING AT LOWER AA P IVIDED. <br /> slwa x /1 04, I J . LLL LC 1 TN. STAFF Q J Q�o 315 I De. 4 5--z-z- <br /> PLOT RAN MI.Ia IRw.I Beala 'le <br /> 1. NAME@ OF STREETS OR TOADS NEAREST TO OR BOIHDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIDIIOBED <br /> 2. OLRUNE OF THE PORRTY,OWRD DIMENSIONS AIA NORTH DIRECTION. EXPANSION OF$MADE OIR'O@AL SYSTEM@. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED @. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,SNCLUDIND COVERED AREAS SUCH AS PATIOS,ORVEWAY8,AND WALKS. ON THE FROFERTY OR ADJOINING FROIERTY. <br /> .. SsL 'RFPRpvED WpRK i�h <br /> Data p5 �� <br /> I <br /> VM T WE ONLY <br /> Applleallen Aeeaefad By � � Dna 4/ l_ji'j���1 J M.a <br /> 0'..Swprlbn Br Ons a Imvrtlen y �T Ona <br /> Orllenkn Innrlbn By Dale <br /> CemmNNc <br /> ACCOUNTING ONLY: AID/ FAC# <br /> PE CODFI FEE INFO AMOUNT REMITTED CPCCK/CAt RE VMD Y DATE PRWSTISERVICE REQUEST NUMBER INVOICE <br /> Pub Heafth SON.-Enviro.173(1/97) , <br />