Laserfiche WebLink
D <br /> 4"4�-FTl[fn <br /> WELL PERMIT APPLICATION FORM UNIT IW <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> L � C.:. 1, <br /> f,,,Zj E I_U ENVIRONMENTAL- HEALTH DIVISION {PHS-EHC) <br /> rrt > Ci- <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMST EXPIRE •YEAR FROM DATE 15SUED <br /> Appitcaticn is nerF!br made:o a-an__,3gL:rt�o r^/fof a rermil to cansirL'c.zndlur insmii:h^wari descr ccd his aoplice!ion's rnacc in Como!ianc:`a:rr. <br /> Sar. Jdaqu:r,County^eve!opment T:ie <br /> chap—.er 5.7 t I5.3 ;r d ine Sla 1dZfa5 at Sar. ;aaau:n Go tnl f?sb:ic lealth Ser�r�v. Er,v ranrental rssal:h DiviS On <br /> W 11th Street Chrisman RTracy 95376 Assess°`5 N/A <br /> WE_L Location C:=ss Street wily Z:r Parcel=F <br /> ' PROPERTYCvjreSan Jo0 quin County .ddre s City Zig PhCrr l <br /> ` Spectrum Exploration <br /> C-57Ccn.rct0: Address 2365 Wigwam Cit)<Stoc 51726' h�re �7�2 <br /> The San Joaquin Company , 8617 Etcheverry _ Tracy 209) 832-2910 <br /> Cpnl;UlUnt:Sub Contactor --ss-ss �ity :cY Pho.^.e <br /> GIS CvOrd.nates:X f Townsnio _— Rance Se[zicr�� t\1 <br /> WORi< TO SE PERFORMEC- <br /> J y�4EW WELL SCIZING(CPT�9E C:�RCdE. HYDROPUNCH_HAND-AUGER.OTHER-) .9 DCS T RUCTION ichoase type oeNwl <br /> i 'VSOIL BOR;NG# O R-aop-E <br />_ fZJv=LL _-- RE SS URE GROUT <br /> ' 'Other <br /> COMMENTS: See Attached <br /> TYPE OF WELL INSTALLATION TYPE . CCHSTRUCTION SPECIFICATIONS <br /> &<AoNITor,&:IG Q MOL_CV7 STEM D(A.OF SOREHOLE 6 rr MULTIPLE CASINGS,Q YES V&O 'hE:_L r_AS;NG OIA2rr f` <br /> a <br /> a FXTRACTIbN 13 AIR`J?.riR6EFi!0RI'JEN CkS+NG'1-SICKNESS SCh SFO TYPE OF CnSRJG: U S T EEr_ U-�"/C 0 CTF-1ER: <br /> a'Jr1F'GR Q`.7U0 RgTAGY [DEPTH OF GROUT SEAL 6' 7-RE11A1f;TYPE TO BE USED: Q AUGERS qAJSc <br /> (J AIR SPARGE 'BUSH?OWI GROUT SEAL PL 7MPED: fes No (NOTE: MAXIMUM FREE-FALL DEPTH is 30') <br /> �/Sf;IL BORING. Q HAND AUGER APPRCX.BORING DEP?`-1 211 &40LTED TRA.FF:G SOX or a;STOVE PIPE <br /> I OTHER._.]OTHER CONDLCTOR CASING PRCPOSEO?No t °EYES I:st_neciFcatior.s rFI: _ _ <br /> COMMENT3: See attached Figure 11 - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 f-ereCy CErify'.h:t I haie prap;iraa-,his aopiice ion anc tfdl lne work wo be-joie in acczMance wit'l San,:oaauln County Oralaarcas. State Laws. an;Rt::-s <br /> and Reat talions of the J'3,q jcaquin Cocn:p. Horreawrer or i:_ensed agen:'S 7ignatur2 '7 cer?f."y that in the performarce of the vcrk <br /> for which this permit is issued. !shall not omptoy persons subject to WORKERS'COMPENSAT;ON Laws of Csf.7ornia.'- '=cntracto's Airnq or<*c- <br /> ccntrac:ing signature:®rtifies the-Wt owing. '7 csrNy&ar in.!h9 oa.fornance of the,.nark p!­;ihtcf7 tssved. i Shall smo'ay persons Sub:er'le - <br /> WORC�'=5'COMPE:VSAT;CA;_..�s o;California.' <br /> THE APPLICANT MUST CALL 48 WORKING :IRS IN ADVANCE POR ALL REQUIRED INSPECTIGNS. <br /> Consultant p_,.e 3/23/00 <br /> .i^yn9'J Y <br /> SEE SITE MuaP IN UNIT ISI WORK PLAN DA►ED: <br /> DEPARTIMENT USE ONLY <br /> Aop4cai:a:'Accertco 91 nen/liL� _ Cate'sued <br /> Algia <br /> Gout Inspector 9? I t�ytn ui,..� _Dated Z anal Inspection 3y Dwe� <br /> I Destruction trsoecdon lav Data <br /> COM,MENT5 1 CONDITIONS: _ <br /> [l_.C_C.O',JNTIN'5ONLY: FP.C.x I __ <br /> 1 i <br /> °E :00ES I rEE INFO AMOUNT REMITTED CHECK fl � RF-C-0 13Y DATE � PERMIT i SER REOtJE5T a � INVOICZ <br /> CLO 52A C) 0 <br /> WIC <br /> OLICENSE LIC24SED CO�TFLkCy- ATION DEC:_AI !L' O-N <br /> Ur'U iV -h/271-99 kvcn bkogiml <br />