Laserfiche WebLink
9-22-1999 A OOPM FROM <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> o <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> *77 304 E. Weber, Third Floor, Stockton, CA , 95202 D� <br /> (209) 468-3460 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appthcatwn is hereby made to San Joaquin County for a perns+t to constmct and/or install the worst described This application Is Moe in compliance with <br /> San uaagwn Gouniy Development Title Chapter 9-i t t 5 3 and the Standards o`f,S_an Joaquin County Putst,c Health 5erveeas,Envttonsme Asessofs� Division <br /> rv'Q <br /> , EVOMPAt Cross Street I I( t City Gk rM Tap_24S v.5 Parcetff �fiv"VQ <br /> Wi_Lt location 4 tL��$� oSF�41�$Ivd C' PhneW <br /> y5L <br /> YS <br /> PROPERTY Owne Address -X306 <br /> e•57 Contractor T`hU" Add <br /> rens IJ�O ►° Cay MA_ Me zrp1Y55 uacs S� 067Phor,eit �5-3r3'SB�a <br /> Phonetf7d7'935' a5'O <br /> Consultant/Sub Contractor blrT a &yJV Address a7Q 2Y ICI tAf 7. C►ty <br /> Lra� <br /> Gt5 Coordinates X - <br /> Y Township Range Sewn <br /> WORK TO BE PERFORMED {� <br /> v DESTRUCTION(choose type below) <br /> OfNEW 1NELLl SORIN< OJLBORlNG# <br /> PT EORODR S UNCH MNl7-Af0 E�-fOTHER-) Q OVER-BORE <br /> 5$ Q PRESSURE GROUT <br /> D WELL t1 <br /> -Other <br /> C=MENTS <br /> EOF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING Il HOLLOW STEM DW OF BOREHOLE_a`' -MULTIPLE CASINGS1 a YES J(NO WELL CASING DIA <br /> U EXTRACTION (j AIR HAMMERIORIVEN CASINGStNG THICKNESS� TYPE OF CASING Ja STEEL 0 PVC 0 OTHER� TYPE TO 8E USED El AUGERS T�R.EMl;= (jliOSE <br /> 13 VAPOR Q MUD ROTARY DEPTH OF G OUT SEAL <br /> o OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ?.ER SPARGE �PUSN POINT MPED 0� 13 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 'SOIL BORING Q HAND AUGER APPROX BORING DEPTH 5 <br /> rJ OTHER <br /> CONDUCTOR CASING P POS N (if YES,fist speaficadons here) <br /> Ot <br /> UU`` NOTE: OFFSITE BORINGS R UIRE A CESS OR ENCROACHMENT PERMITS! <br /> 1 hereby certify that i have prepared this 39pllcauon and that the work will be done to accordance with San Joaquin County Ordmances.State Laws,and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent's signature certrhes the following "1 certify that in the performance of the work <br /> for which this permit is issued,l shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Calitomia." Contractor's hinng or sub- <br /> contracting signature certifies the iollowtng J certify that in the performance of the work for which this permit is issued I shat!smploy persons sub/ed to <br /> w0RKMAN'S COMPENSATION Latw$of California' <br /> AfUE APP CANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> C <br /> 9&a "."LfSigned z Trge7 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 17<1171z <br /> DEPARTMENT USE ONLY9� <br /> —O &.Date Issued ea <br /> Appl=tcon Accepted By Date <br /> Grout Inspection By nate Final Inspection SY <br /> Destruction ln5pectton By Date <br /> AI&OMMENTS 1 CONDITIONS <br /> FACT <br /> ACCOUNTING ONLY AIDS <br /> PE CODES FES INFO AMOUNT REMITTED C}IECKis'lCASH RECEIVED BY DATE PEitMITISERVtG�RI~ NUMBER INVOIGI <br /> �D2-(O d ( !� <br />