Laserfiche WebLink
01/31/2002 11 51 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM _UNIT I1� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c <br /> ' ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 -G--� <br /> (209) 468-3450 <br /> 1333C <br /> / NON-REFUNDABLE PERMIT EXPIRE YEAR FROM DATE ISSU <br /> Application is here y made to San Joaquin C my for a per nst an o ins a I t work desCnbed his app6 ion is made 4r%oomp4ance with J <br /> San Joaquin County Development Title,Chapter 9-1115 3 and the Standards of Sa aquin County Public Health Services,Environmental Healttan 1, <br /> 51 R ASsessoes (6�� 7f '�✓ <br /> WELL Location 133; Wim_ Cross Street V City ST 6 C r T 0 N zip 95 Z 0 y Parcel# <br /> PROPERTY Owner N VS11~E Address _ City C Zlp Phone# <br /> C-57 Contractor ORI 4 KCr� ESTING ddress g 0 H6Wl: ROAD City`.��RTeN�lzjl, 5S Lso#b364O-tPhone# 313( 5$00 <br /> Consultant l$Ub Contractor R lit KMLt4t?rLV Address G-+ E- 10T .T City.!P,Pt LY Lic#6S IS O1 Phone# B 3 0-1S <br /> GIS Coordinates X 1 ,Ta+rrship Range Section <br /> WORK TO BE PERFORMED <br /> r I NEW WELL I BORING(CPT GEOPROSE,HYDROPUNCH,HAND AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> I SOIL BORING# C P T- p OVER-BORE <br /> ()WELL# p PRESSURE GROUT <br /> ' 'Other COMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2•IIS MULTIPLE CASINGS?0 YES N NO WELL CASING DIA KA <br /> 10XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING 0 STEEL Q PVC D OTHER NA <br /> APOR. Q MUD ROTARY DEPTH OF GROUT SEAL*1)N 115! TREMIE TYPE_TO BE USED 0 AUGERS BHOSE <br /> 0 AIR SPARGE Q PUSH POINT(GPT) GROUT SEAL PUMPED @ Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />' ®SOIL BORING D HAND AUGER APPROX BORING DEPTH 11 S/ 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? NO (if YES, list specifications here) a1A <br /> COMMENTS THIS CPT LoCATIOtA WILL be otA FA1RFa02VA05 NEAR MW-4 114 STEAD OF <br /> rF_KTE.R LArNt-1 OF C4AR?6R WA�f. CCTT of 5[Ot,KTOR VtN1E0 E14CR0A0AMEKT_ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />' I hereby certify that I have prepared this application and that the wont will be done in accordance with San Joaquin County Ordinances Stale Laws,and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signature certifies the following j7 certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSAT101H Laws of Cahfornla" Contractors hiring or sub- <br /> contracting signature certifies the following "1 cerbly that it)the perfomtenoe of the want for who ch fhrs permit Is issued I Shell employ persons subject to <br /> WORKMAN' COMPENSATION Laws of California" <br /> APPLICANT ST CA9LSI�HRS IN ADVANCE FOR ALL REQUIRED INSPtGTiONS. <br /> Signed Title Date <br /> SEE SITE I UNIT IV WORKPLAN DATED mkP loth cIUR <br /> /t UME USE ONLY �il� ,R r� � tea_ <br /> Application Accepted By l-� issued <br /> Grout Inspection By Date f=inal Inspection By Dale <br /> Destruction Inspedion By Date <br /> APAJ ri <br /> COMMENTS l CONDITIONS �� r � t f � , � u - <br /> 1 r e ,s t� <br /> FAC# rdM <br /> CCOUNTING NLYI <br /> AID# 12 r 1i Z <br /> PE CODES FEE INFOUNT REMITTED CHECKfl1CAA C D 13Y DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3 4 ` r .0 � <br /> uNTT rV-6/1/99/Sinn bkpg/MT <br />