Laserfiche WebLink
WELL PERMBY APPLICAMN FORM SITE <br /> TON <br /> SAN JOAQUIM COURM PUBLIC HEALTH SERMES MOTIF A <br /> EMVIRONMENTAL HEALTH DIVISIOM (PHS-EHD) <br /> Pf <br /> 304 E.Webeir,'mord Moor, Stockton, Com, 95202 <br /> - - - (los)46&3449 <br /> NON-REFUNDABLE PERMIT E%L'IRES 1 YEAR FROM DATE ISSUED <br /> tppiication is hereby made to San Joaquin County for a permit to construct and/or install the work descnt; d This application is m8d9 in c0mp1a8neer with San <br /> €oaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public health Services,i=nvironmenl Health sDIMS= <br /> AssesSO' WELL LaeatiamT Cross Su+ast aCt+al 1d u, _City �TCF�T�h7 dip �•Se?O�Parcel. <br /> IROPEImOwner r Address <br /> :.SZ Contractor �-W /cuiG Address •O, fax 4IG City.=&-0r&.a,ztp9V,6gi LIaOZ9�ll Phone# :P/677A 9/00 <br /> :asnsultant t Sub Contractor Address City i_ICf��_Phone# <br /> ;IS Coordinates X Township Range saacdon <br /> ' Nam To BE PERFOR1tAED: �bESTRUCTION(choose type below) <br /> %JEW WELL I BORING(CPT GEOPROSF-HYDROPUNCI�i,HAND-AUGER.OT6 MO) VERvBORC <br /> Q SOIL BORING# jimssuRE wour <br /> p WELL;t w ' grout Sons: <br /> 'othaer. <br /> :OMMENTs. D EST2&-a TioN <br /> TYPE OF13UtEt i INSTALLATIOM TYPE CO ISTRLIC9 tOR1 SPECIFICA 4 5 �v <br /> lViONITORING �}IOitow STEM DIA OF BOREHOLEr o ', RtULnPI-E GASV9W 13 YES }1NO wa I CASING wc—_ 6 <br /> j EXTRACTION II AIR HAMMERIDRIVENt CASING THICKNESS-Cc* _._TYPE OF CASING Q$Tilt- PVC D OTHER <br /> goVAPOR Il MUD ROTAEZY DEPTH OF GROUTS TREMIE TYPE To BE USED. Q AUER <br /> GS ktaOSE <br /> AIR SPARGE E)PUSH PoiNT GROUT SFAL nUUpeD gree p ma (NOTE: NAMMUM (FREE-FALL OEMIS 30 <br /> ,SOIL BORING n HAND AUGER GROUT SPECIFICAMONS [Aare C. 6rag- se. <br /> O-T)iER.,, B OTH(-7-R APPROX.BORING DEPTH Lag _SeOLTEa TRAFFIC SOX or 0 STOVE PIPE <br /> ' CONDUCTdR CASING PROPOSED? AIp--t ifYE3.list spe*r=tFons here?. <br /> -COMMENTS. <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> ' CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I GZemby certify that I have prepamd this appiicAGn and that the work will be done in accordance VArkh Saco Joaquin <br /> ' County Orditn s.Rules and Regulations,and all applicable Califamia State Laws- <br /> ,anyx <br /> Tlftcompany aE 1 Gp aE <br /> Print Namivi5f/If' Date /! 6 O f DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE,AD KESS: <br /> WORK PLAN DATED: <br /> r Area <br /> Application Aomted By i t d w_w w//qtr.. <br /> ' Grout InspecLan BY _ " Date Float Inspecbon By <br /> Destructlan Inspection By Date <br /> COMMEt1TS 1 ecoorno"s <br /> ACCOUNTING ONLY AIDiL <br /> PE CODES FEwE IAIFO AMOUNT REM�D CHECK# REG'D 13Y DATE P IITJ$ERVICiE RE42Ul!VT� tNVOiCE <br /> ' 3 �z -60-0c) o3f�,z16 tit Is of zoo <br /> G-57 WG -WAjWR C-57 Letter of Authorization to sign pat-Wt Encroachment doc sI 700 <br /> 1 <br />