Laserfiche WebLink
0 0 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EMRES 1 YEAR FROM DATE ISSUED <br /> Apolioat;on is homily made to San Joaoum Cnunty for a oetmit to consVua ardlor instal the work descnbed Tho app6calion is made in compkance with <br /> San Joaquin County Deveio9ment rMe,Chapter 31115.3 and the Standards of San Joaquin County Pubtw Health Services, Environmental Health Division_ <br /> 315 S. Center Lafayette Stockton 95212 A�oex 137-31-10 <br /> WELL Lo tion Gross Street City 2qr Rwmw# <br /> OPV <br /> FROpERTY owner IBPOE of W. Lodae10%bahoas P.O.Box 691985 City. Stockton Zip95212 Ptronele <br /> c.57 Contmaor Vironex, Inc. . Address 23.726 Foley St. #7 city Haywardzp94326Lk p 7059Aaorx# 510-266-0966 <br /> Consultant I Sub Con"= '14r✓ining Labs, IncAddres52527 Fresno St. City. Fresno Lim pnoneP 559-266-7021 <br /> GISCmrdinateavXLat 37 57. 365 YLonq 121 17.473tow&* Range Section <br /> WORK TO 8E PERFORMED <br /> ff NEW WELL I BORING(CPT. EOP�RCBB''HYDR(:>PUNCH. WAND-AUGL-R.OTHER-) a 0ESTRUCTION (onpoae type helaw) <br /> USO BIL ORING L 0 OVER-BORE <br /> xB WELL 0a,11T6`T'9,i;;q,6FL3 r 6114 0 PRESSURE GROUT <br /> 'Oflter, <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DA OF BOREHOLE 1 112 1j7DLTtpLc CASINGS?U YES b NO VVEU CASING OLA_ <br /> 0 EXTRACTION 0 AIR HAMMERJORrVEN CASING THICKNESS NTA TYPE OF CASING: 0 STEEL 0 PVC D OTKM- <br /> VAPOR 0 MUD ROTARY DEPTH OF GROtT SE4�L 'fit TREMlE TYPE TO BE USED: 0 AUGERS OHCSE <br /> 0 AIR SPARGE 6 PUSH POINT GROUT SEAL Pl1AAPELT. p ves (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH 5 t <br /> G,U 0 BOLTED TRAGIC SOX or 0 STl7VE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? (If YES.rM specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> ! hereby mortify that I nave prepared this application and that the work wre be done In acconlance with San Joaquin County Ordinances,State Lawn.and Rune: <br /> and RegutatioM of the San Joaquin County. Homeowner or licensed agent's signature MitifieS the f09gwin4 "t certlly that in the performance of the work <br /> ror which MIS Penna is Issued,I shall not employ persons wbject to WORKMAN'S COMPENSA77ON Lave of Califomie." ContnIctort hiving or Wb- <br /> contracting signature certifies the forming: 'l csrdfy UW in the perlgmUw'*e d MB wwX for which this pettnh a issued. I snO employ petsom zubjeIX to <br /> WORKMAN'S COMPENSATION Laws of CaRb7 ia_' <br /> // TH APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed zL l� t Tiive f'er`alk l-TA'1'77. 5,4t wie Date i2/6�f <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 12iei99 <br /> DCPARTMENT USC ONLY <br /> Aooketion A eoted By Dale Is_vrred Af*a <br /> Grout Inepectien By Date Final InsoeCtion By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FACS <br /> ACCOONLY: AID# <br /> PE CODES FEE INFO AMOUNTED REMITTCHECKS/CASH RECEIVED BY DATE PERMIT15ERVICE REQUEST NUMBER INVOIC <br /> I <br /> UNIT IV-5/99/MF <br />