Laserfiche WebLink
F` 73 <br /> e <br /> i <br /> L WELL PERMITAfi <br /> O <br /> IN F RM UNIT <br /> SAN JOAQUIN CO IV <br /> ENVIRONMENTAL HEA Tl jUL 1p1VISALTH SERVICES <br /> 304 E. Weber, Third Floor; StocktoO CA., 9,z H�) � � <br /> OZ O ff - �� r <br /> (209) 465-3449 ��•�-�ID <br /> PALY <br /> � <br /> Application i5 hereby made to San Joaquin County fora permit to construct andlor install the work described. This <br /> ON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of S n Joaquin County Public Health Services <br /> (f application is made in compliance with <br /> WELL Location 7 1�r ZD C� ` , Environmental Health Division. <br /> Cross Street 2 S City S Cre, G Assessor's f' <br /> PROPERTY Owner J - 2ip—�� �� Parcel# } <br /> �� L Address E ,� <br /> ttllss { _ � rCityJ � iPuZ Pho e#" <br /> C-57 Contra l+w1`�" Address323 �t <br /> 3zity CPc��l�ZLicS`t r� 1>-� <br /> —��Phone# 7Z 7(0 <br /> 6siDta <br /> /Sub Contractor 1(� Address t10� I V 1 r+. �. / <br /> +'144 S ic# Phone# A /-&, <br /> GIS Coordinates:X Y Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED <br /> /ff<EW WELL/BORING(CP , EOPROBE, HYDROPUNCH, HAND-AUGER, OTH R' k <br /> a DESTRUCTION(choose type below) <br /> OIL BORING# - <br /> WELL# <br /> 'Other: OVER-BORE <br /> PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?a YES 0'/NO WELL CASING DIA: Z �f <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: d STEEL PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ,�UGERS pHOSE <br /> ©AIR SPARGE a PUSH POINT GROUT SEAL_PUMPED: a Yes ,goo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING (]HAND AUGER APPROX. BORING DEPTH eD '?v I,+I— BOLTED TRAFFIC BOX or a STOVE PIPE <br /> a OTHER:_I]OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: Qyvy� �—vN�y -711 <br /> 111 <br /> NOTE: OFFSITE BORINGS REQUIRE ACC SS 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: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE'APPLICA NT,MUST"CALL 48 WORKING HRS IN'ADVANCE"FOR ALL'REQUIRED INSP CT ONS. <br /> . . <br /> ra z <br /> Signed x Title � �� Date <br /> i <br /> i <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: l <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByQDate Issued 0` r �C z � Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPERMIT 1 SERVICE REQUEST# INVOICE <br /> �3l �j !2 U �-/ Ob 2— <br /> C-57LICENSED CONTRACTORMUST SIGN,LICENSE &WORKERS° COMPENSATION;DECL:ARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />