Laserfiche WebLink
VIZOAQUIN <br /> LL PERMIT APPLICATION FYRM UNIT IV <br /> COUNTY PUBLIC HEALTH SERVICES MAY 18 M <br /> MAY 16 20 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENTAL_ HEAL E. Weber, Third Floor, Stockton, CA., 95202 A <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made In compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 95 7 6 ar 2_SO lb <br /> WELL LocWon S4S1 W.6A tUC%]nov 405 Cross Street ' City ('aLV Zip pAessor's <br /> cew <br /> PROPERTY Owner o Address 33d E kwivardl) City Tmill Zip_2YD6-Phone# <br /> C47 Contractor lAi6tefl DA ddress f1A0C,- W4ffhL& city Zip '���Lic# G7.V7 Phoneiit alb - U <br /> Consultant/Sub Contractor {t Address goasM AJ lsrral 1V! City 1,Lic#6�Phon oS 4� 7- �` <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> JNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> )SOIL BORING# 0 OVER-BORE <br /> ]SWELL# r W 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> it <br /> MONITORING tHOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?0 YES 'WO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS f,—TYPE:OF CASING: 0 STEEL .WVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: *UGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 1KNo (NOTE: AXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED?_A_/,'I- (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the work <br /> fi�which this permit is Issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signateire certifies the following: 7 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company sle, t N l S+ <br /> Print Name r ct V1 Date 5-- S� <br /> DEPARTMENT USE ONLY <br /> Application Accoepted By Date Issued �� . Area <br /> Grout Inspection By Da f=inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D 13Y DATE PERMIT/SERVICE REQUEST* INVOICE <br /> O A9.0Q 1 /3 aozzgo6 <br /> 1/18/2000 <br />