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08/07/00 13:34 FAX 407 650 36?'° N*ND; LEGAL _00 f <br /> J <br /> Dy <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUB�1C HEALTH SERVICES. FILE <br /> � <br /> ENVIRONMENT HEALTH DryISION (f HS EHD <br /> 304 E.Weber, Third Floor, Stockton, CA., 9520 <br /> (209) 468-3449 '. <br /> i <br /> NfaAO t=R{4lI ES` <br /> NO iicatian is made In compliance writs sacs <br /> ApPlicadon Is hereby made to Sdn JoaRuin County for a perm;;to construct andlnr in5ta111�ie inrark desorH@Rl This app <br /> ntTide,Chap pssessa�s <br /> ApplicJoaquin County r evel°P oar 9 1115.3 and the S�ndar at Sen Joaquin County Public Health Servloes.Envlranrnerllel Health 9 <br /> .{ �;p q�3r1�Parceltx'2 3f3-ozc3_�,o L <br /> Ofi� masa sheet �- ZJ�7 Clty Ti°Jk� <br /> tAi>=LL LocatlenA�]i10 b wr - ,tr City.oYcar,Ga vp az�soi Phone;#I'�tot)Lnr.�-Ino . <br /> PROPERTY Owner C1�1 i-�S �- Addresses <br /> C-67 Conty ice` G- Address 4 <br /> C MMESe•� U Gily `�'`G ZIP`irj815 Lic#!�q`�`?�P�Phare# <br /> Address Z31�j Wi(a►,IAM M• clty siocic rc.�Lic# I�Z7k$ Phvn� �2-9 SFIv rr-87jZ- <br /> Consuttant j sub Contractor SGT �.:uTi; fL'cn9e f46T Sedan I q <br /> Township <br /> GIs Covidlnates:X <br /> WORK TO BE PERF *ESTRUCTION(choose type bele-) l <br /> ROVER-BORE <br /> [�NEW WELL!$ORiNG(C.pT.GE.OPROEE'HYt]ROPUNCH,HAND AUGER,CIFHER'� v_ Q PRESSURE GROUT <br /> Q OIL 13ORING# <br /> ELL <br /> 'Other <br /> CO1yi mENTS: <br /> INST LAATI N E �CONs UCT ON SP FIC ONS NO W ELL CASING DIA: Z <br /> g Op LL Sin! " MULTIPLE CgSlNG5? ]YES Q <br /> MONlrOR1NGHdLLOW STEM OW,OF BnREHOLE�_ <br /> �.F RAGTION [I AIR HAMMERlDPJ CASING TNICKNES$ 40 �'PE C}I=CASING: jJ STEEL PVC��v���JJ"""p pT F?.S <br /> 13VAPOR jj MUD ROTARY <br /> DEPTH OF GROUT SEAL' Z i=ce TIMIE TYPk TO t3E USEo= IIGEFtS []HOSE , <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPEO'l Yes II No (NCiTE: MAXIMUM FREE-PALL DEPTH IS 30') fI <br /> Q : APPRdx BORING p 2Z r —13 EOL TRAFFIC BOX or ASTOVr_PIPE <br /> d SOIL SOft1NG n HAND AUGER (tf YES,list speo[Ications here)- <br /> OTHER <br /> CONDUCTOR CASING PROPOSED? <br /> �� <br /> 0 OTHER: -Q . <br /> RINGS REQUIRE ACCESS OR E!�lCROACHMENT PERMITS <br /> COMMENTS <br /> NOTE: OFFSITE Ba G In Counb Or5dlnancesi'state Lam,er�d Rules <br /> in goaordanae with�,an �a9u that fn the per/pance of the work <br /> I�y PmKIV that I hays prepared th'4 applis�tlon and that the ward ap 6e dans �,re�fia6 the fallc)N La: f certifysub <br /> at to WI'�RKERS'COMPEMSA77r)N Le WS of Ca7ffiyrnia" Cto per �s hiring or to <br /> and Regulations of the San Jrraquln CactntY- Harrleowner or licensed agent's sig+sa ��is issued,1�',alf amp>oY!!e�"s��to l <br /> for which this fern is issued,f shall flat enWoY P�a'rj 6 wf ance oohs wo*for which Phis F <br /> oontrae6ng signature certsfles the foliawtntl= that 1n the perform " <br /> WORt(ER5'COMFENISATION Lews of Gafifami^' <br /> } HL-1-THE UNIT 1V IN PECTOIR 4B{NORKlNG�iRS IN ADVANCE p'C]R ALL REQfUIRB[l fAISPECTi3OIN��9L <br /> ---� ee,7 ntielGompany'Sf1•C �(h�_ST• ,~tr7/�'Z fh�dfJ <br /> siignad K I` <br /> ,5;ADEE!S 17ate <br /> Print Name ai,)67 <br /> SENT E�ONL <br /> ' Datelssued_ Z.2,0C <br /> Application Accepted aY Data tF ;m Final Instae sm By. <br /> Grout Inspedlon 8y DE <br /> Desutcgan Inspection BY v ! <br /> COMMENTS l CONt3 f1OMS: I <br /> ACCOUNTING ONLY_ AID# <br /> CHECK <br /> FlEG'D 9Y: OATS pERW 1 SERVICE'MOUEST I iI+IYOICE <br /> Pp.CODES PEE INFO An�oUsvT f�EE1tCf'rED � <br /> 2q D 2— �D r 5/17/00 <br /> C-57 exp. <br /> WC/waiver G-57 LCtter of Authot•izatierl to sign pertrllt ERcroachmenfi dq't{s]. <br /> A 39tfd <br /> 2600-3 HlU1� SEtiE83b60Z VE 1:V1 020Z/90/50 <br />