Laserfiche WebLink
06/07/00 13:34 PAX 407 650 361" _ NNN LEGAL.__ Z003 <br /> VVELL PERMIT APPLICATION FORM <br /> UNIT IV ' <br /> SAN JOAQUIN COUNTY PUBLIDIN Sl1DN DIVISION ( % � . <br /> ERVICFILE COPY. <br /> ENVIRONMENTAL HEALTH <br /> 304 E.Weber,Third Floor, Stockton, CAS, 95202 , <br /> (209) 468-3449 <br /> 4 . <br /> NDA9 pA141 lEJJ(Pl FS ROM ATEA <br /> NO isatian Is made In corn <br /> pliance w1C1 San <br /> Application Is hereby made to San,lpsquin Countyfor a Permd GonstruLt anter 1n,,1,C9 wads desert Health <br /> This ice <br /> !o int rdle, p Assessors <br /> Dene p Otte ter 8'111 S.3 and ttte Standards at Sen.fosi;u4n County Put>Iib HeaIH r Services•Envlronme*rial Heal 3 ivislan <br /> Joaquin County . ZOS C1n, -�}C' dip CI25_ 1 <br /> —gyp �1 f pq i) _Crash 8treeE <br /> WFLLLoextlon PcANGA Z1p '%3-�i <br /> PFiQPER3Y OwnQr CN x-125 C- Addresses 0 2a ��tF Glry •• def_?Z Qo <br /> Ih �,/t�, �i5gt5 Lic#q4�,.`jo6 Qh ne# 911 <br /> 23.. Gity�,�_ .pP <br /> C-67 Contractor Y: �Cl Mire I <br /> p d„asg-Z?,U6 WI�1,:fAr-t'M• City <br /> �(pLK ro,_ljUC# 51�.�Phoria Czo9 �F�yS-S712— <br /> eanSultaM!sub Conti-actor �- �k 5;u rA R:tnse 'e ST Sectlon �l . <br /> v .Ta++nehfp� <br /> G15 Coardlrratea:X <br /> WORKTO B F-MMIRLF <br /> E5}FiUCT10N(choose type below) <br /> HYORbPUNCH,HAND-AUGER,t]TF{ER') <br /> AVER-BORE <br /> 0 NEW VV ELL t SOWNG(CPT,GF-OPROSF, � � � � ,PRESSURE GROUT <br /> - <br /> �. <br /> COMMENTS: <br /> - � CORS U ON'tSp r ON5 it <br /> EOF WELL 11VST �`� N E Sin! MULTIPLE CAS!lVG57 U yES []NO WELLCASINGDIA: Z <br /> MONMORING k{bLLOW STEM DIAL OF BOREHOLE_ HER U OT <br /> _ <br /> EXTRACTION AIR HAMMERIDRIVEN CASINGTHICKNESS� TYPE�l CASING: <br /> E TYPE TO PE U8E"'VC UGEFLS �i�OSE <br /> h VAPOR 13 MUD ROTARY DEPTH OF GROUTS 1 �---� <br /> El AIR SPARGE p PUSH POINT GROUT SEAL PUMPED')Yes 13 No (NME: M"MUIUI FREE-PALL DEPTH IS 30') <br /> p SOIL DORING 13 HAND AUGER <br /> APPRO}C 60RlNG DF��T1 .22 �• _p BOLTED TRAFFICofST0111:?IPF_ <br /> TOR CASING PROPOSED? ^(RYES.list sPrjClticatons hen:}: <br /> CONOUC <br /> c15�tM rs• BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> NOTE: OFFSITEwith State Lays,and Mules <br /> I hereby ca"that I have prepared this appliFxean and that the work wlll be done in accordance he�Asn Joaquin County <br /> Or tr:6he par{orrr,ance of the work <br /> Regulallons of the San Juaauln County- Hmnaowner or licensed agents signage eutifies the iallowtn9'.f CoatiaCta�s hiring or sub- <br /> andIhr which this P"wh is issued,t aloft not emPloY parsons subject to NIOftKPRor for whkIh 6W3J Laws sswd,l emptaypersans subjoct to <br /> oontmc5ng slgnature�•erbdes the tnlfawlng'"!�Y that fn the performance afthc work for which this} <br /> waRKER5'C,bMFIENSA77ON Laws of Caftmia,' <br /> �'j <br /> {svl..L THE IINR 1Y 1�1 pECTOR 48 WORKINGHRS IPt ADVANCE F'DR pit REWIRED INSPECTIONS . <br /> �.Qtv �►" '� 71GetGampany"�f�•�7I <br /> Signad is <br /> Pdnt Name r� <br /> J � S L <br /> is J :' ._�. .� :i���'}.day•:1 •••IlIA.r. <br /> _ _ _ 4 _s .,!�..�'r�� %i�.�.1y�t'��� �meq_" --— t��.:�+•�•.-.,sin. <br /> D ENT >;ONL ------ re <br /> aa <br /> i. Date Issued_ - 2•?.oae <br /> Appilcation Accepted E4y Data t �' Final InsP�+rrt BY <br /> Gmut Inspactlen ay <br /> a. <br /> Deatrucbon Inspedtcn By Data <br /> Lab <br /> COMMERM 1 CONDITIONS: ;1 <br /> h <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT RENRTTED GMECK# f' ' <br /> BY D <br /> ftEG'D ATE PERMITI SERVICE RE2UESTI INVOICE <br /> 29 0 i l3J _5/17/00 <br /> C-57 e-xp.� WCf�iver� G-57 Letter of Authorization to sign permit' ✓ EncroaChrlr�n� dQt(s). _ <br /> b0 �J�7d �pa'1� NI�Y� SstieagtGo bE:til 60i3Z/seise <br />