Laserfiche WebLink
OCT-05-1999 08:47 CAMBRIA 510 420 y1(U r.Uelue <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209)4GS-3449 <br /> NON-REFUNDABLE PERMIT EXPIR"1 YFAIKF O DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct and/of install dw work d9%=1;90. Thu application is made its COtlt¢IiariCe with <br /> San Joaquin County Development Title,Chapter 9.1 i 15.3 and the Standards of San Joaquin County rubiie Health Services.Environmental Health Dry��D+�Q <br /> trllELt.toeatian a► Wm} �Ibtl Ln-Crews street f. city Zip �D Pareat+� bS�— <br /> PROPERTY Owner Ot( Cgk#Ak g64ares ee'F CitY��.Mzip f� Phone* Z6y6 <br /> C47 Contractor AddtraS )3,. � �JCr�fty,J` 1iP Lias tW�3�hene! � r7 S <br /> ConsutteatISub Contractor Addfess�11y� `$fit�1 crty��l� axone a�3 yD <br /> GIS Cowlnates:X„ - l Y .Township—QA)-- Range a� Section <br /> WORK TQAE PERFORMED <br /> 0 NEW WELL ORI toT I;QPR06E.HYDROPUNCH,HANG-AUGER.OTHER-) O DWRUCTION(choose type below) <br /> p SOIL BORING ti 2- O OVER-BORE <br /> O WELLS O PRESSURE GROUT <br /> 'Other <br /> COMMENTS: <br /> TY WE INSTALLATION TYPE CONS RU SPECT ICATIONS <br /> O MONITORING O�iOLLOW STEM OLA.OF BOREHOLE ' - MULTIPLE CASINGS?DYES ONO WELL CASING DIA: <br /> O EXTRACTION O AIR MAMN PVORIVEN CASING THICKNESS--- TYPE OF CASING: O STEEL Q PVC p OTHER: <br /> O VAPOR O MUD,ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS ONOSE <br /> O AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH 15 301) <br /> j501L BORING o HAND AUGER APPROX.BORING DEPTH Q SOLTI<0 TRAFFIC BOX or O STOVE PIPE <br /> O OTHER: XOTHER F COHDi1CTOR CASING PROPOSED? (V YES,list specifications here): <br /> COMMENTS: 0hwidw ` <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cenity that 1 have prepared this applicativn and that Orw-00k will be done in accordance with San Joaquin County Ordiftm=.I,State Laws.and Rules <br /> and Regulations of the Son Joaquin County. Homeowner or licensed 20efIrS signature certifies the following:1 certifY Ehat iA thePerformgnCe of the work <br /> for oh;c*this Permit is issued.I shall not employ persons subject to W0RK9*S'COMPENSATIO/V Caws of Carl) mia." Contractors hipny or sut,- <br /> contmcting signature cwb%s the following:'I certify that in ft peAbnnanoe Ortho work forwhikh this permit is issued.t shall employ persons sub/Oct fo <br /> woAKFRS5APFLI!� <br /> NS+4T/ON farts of Cafiibmis." <br /> MLa1.STCALL 48 V 6iWNG HRS-IN Ap <br /> VA�ICE EFOi ALLREQUIREb INSPECTIONS. <br /> Sign x TbE f Date 9- <br /> SEE SITE IN UNIT IV WORK PLAN DATED: a, la., 1 279 <br /> DEPARTMENT USE ONLY <br /> Appli=tion Acespted By Date losved <br /> Grout Inspection By Date Finar inspection By Date_ <br /> Destruction Inspection By �, �r� � _ Date 9 '7 <br /> COMMENTS I CONOITIONS: - - <br /> ACCOU"NG ONLY' AIOM fto <br /> PE CODES FEE INFO AMOUNT REIMiTTED CHECK a RECO BY DAVE PI:RMrf/SERVICE REQUESTS INVOICE <br /> CID S -7 3 <br /> C-511-11CI T$F co CTORMUSTISIGN X.IM ME.8tW4R 1L ':66MPFNswnbN DECLARATION <br /> WaT N-6/23/49/sign bkpg/MI <br /> TOTAL P.02 <br />