Laserfiche WebLink
qD �� U <br /> CCn <br /> Ul <br /> _ <br /> z cn WELL PERMIT APPLICATION FORM UNIT IV <br /> Uj <br /> I �a• cr� 5 <br /> -2' :z SAN JOQQUIN C04JNTY PUBLIC HEALTH SERVICES <br /> ' C II ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> F <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> u-1 (209) 468-3449 ! <br /> NON-REFUNDABLE PER?AIT EXPIREI YEAR FROM DATE,53UED <br /> Application it hems•,made:c Sari_:)aqu:^Casrty Ioi a permit to Construc:and/or install;Cly w7fK described -his applicz`ien s rrta�e it coraFznca rc:rc <br /> San Jaagwn County Oevelopmen:T,te.Chap:ar 5-I 115.3 and the 3landarCs of sar Joacum Coinly Public Health Serails, Er.v ronmentat heal'.h Division <br /> 75 qoW llth Street Chrisman R&. Trac . A Assessor <br /> WE_L Location C:�ss 5seet :<{ y Z:t� Parc�i# S OSS - /7 <br /> Navarra <br /> t <br /> PROPERTY OvanerCarl & Annatltae ;- lr;Hr�s 475 W _city Tram-_ _ Zia CA Phcneg(709) 36-0005 <br /> Exploration 2365 Wigwam Cil�tocktony,p 95205.-512268�h�.;e 4209) 465-8712 <br /> C-57 Crn;r:ctor Spec tri Adzirross - — _ <br /> Conxultatit;Sue Contr2cto he San .Joaquin Co.;dress 8617 EtChevBrr Y;:} Tracy _C� Pna.^.e(�?,�) _$�2-2910 � <br /> GIS C�ard.nat=_s:X Y Towish;o R.anye 5ecrior <br /> WORK TO BE PERFORME^_ --� <br /> F "9.1"NE U WELL r BORING',(CPT�, EC?RCBE, HYOROPUNCH,HAND-AUGER.OTHER*) 8 DESTRUCTION r_;:oase,ape oeiowj <br /> US OIL BORING# Q CVER-2ORE <br /> trWELL#-- *"PRE S S UR E GfJOUT <br /> t COMMENTS: bee t"tac`Tie <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �--4 <br /> _0N[TeRING �F ou-civi STEM OLA-OF BOREHOLE MULTIPLE CASINGS--[}YES �NO J4E_L CAS;NG DIA 2"__�/ <br /> a EXTRACTION a AIR,`MAlI,MERICRtdEN CAS!NG7HiGKNESSSv_h 40 OF CA'+ ING: a STEEL Vn1/C 0 C7H_R- <br /> a VAPOR 0'iuc ROTARY OEPTH OF GROUT SEAL 6 'RE=VUE TYPE TO BE USG7: I}AUG€RS Q90SE <br /> Q AIR SPARGE 'e-USA POINT GROUT SEAL PUMPED-, V/'fes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> f <br /> 1j(Sr:IL BORING. a HAND AiJGER APPRCX-30RING DEPT-I 21, kJOLTED TRAFFIC BOX or p STOVE PIPE <br /> i ©OTHER: a OTHER CON:)LCTOR CASING PROPOSEo? No {1YES t 51:E ovciftc3bors <br /> canrs�I=*CTs: See attached Figura 11 ( } <br /> ri NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I reraCy�:2r3 <br /> ify that I have prepa- 3;his aoplictixcn anC tha;the work wi4 De,�xie in a=rrJance w:t':5art.:ga']:Sln COUrty OrdlnanesJ.$:3[4 Laws.3nd R,;:= <br /> and Reaciations of thQ Sa+Jeaauin Cgcn;y. Homeour:er or 4:censed ages's sigma;,re Ce t!fi_s,he'oIl,:,,pq : oe perfbrmahce of the svcrk fff��� <br /> For which this perrrsit is iSs:ied. 'shal)riot amptoypersons subject to W[]RKERS'CDk1PEMSAT:ON Laws of C.31.1brnia.- C0ntr3cto"s nira4 0r S `r- <br /> cenirac:ing signature;artifies the =o!Iowing: 't a5rtify ae.•fannanca o`i-ne•.cork`or:•ihich this permrr i;issued. i shalt em.;D'cy pe«_ns Sub eC:to <br /> WOR+CEr 5'CL�MPfi;+15:,4T;Ch'_s+vs o;Califor»ia.' <br /> THE <br /> APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTICNS. <br /> Si�nadX 1`�' Titia Consultant Dee 3/23/00 <br /> SFE SITE NIAP IN UNIT IV WORK PLAN DATED: <br /> I DEPARTMENT USE CNLY <br /> Awiicat,o-Ac;eoteo By Utn _ _Cate 'ssued qA'C> A.rea�. <br /> G'outinsp^_ior Sy (_/ C" DateA 't '7t :lnal Inspection By <br /> Oeetruction irsoecrion By <br /> COMMENTS 1 CONDITIONS; <br /> ACCOUNTING ;ONLY: l :IC's i <br /> 'E CODES PEE INFO AMOUNT REMITTED I C"ccx.A I RECD BY ' DATE PEP14ilT;SEf7'JICE >ZEGUE5T 1NVg10E <br /> SR# Q <br /> C•37 LICcIVSED CONTRACTOR MUST SIGN"UCENSE&WOizKF1tS' CGtilr F_NSATION D£C;A11UITCON' <br /> UNIT i V -6/M`91?/Sign hoc.;iME <br />"In <br /> r <br />