Laserfiche WebLink
95/18/2909 14 56 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPUCATION FORM UNIT IV <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE�� <br /> ENVIRONMENTAL HEALTH DIVISION (PNS-EHD) t <br /> 304 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> (20Sr468-3449 1PH <br /> ETJ✓rr��r�N rl, <br /> �tOk-FtEF[ltHQA6LE pERMfT EXASRE$ 9 YE4 FROM DATE 1SSlJEI] ppA�r <br /> APPGcation is nereby mace to San Joaquin County hu a cerm+c to construct artdot+-stall Ole worts described, This apptrcat�l�0ACTe i^ '?�F��n�.c <br /> San Joaquin County Devetoornerq Tide Chapter 9-1115 3 and the Standare:of San Joaquin Countyrx � e�Public HesM Servi <br /> s Er,vupnm@rnal}iealtri cion <br /> YELL Location Crass Street� _Dt[,,�_eC, AssES',Of S <br /> ry S P�SAO parcaltr OSS--3J-c7—I Q <br />)ROPBRTY Owner {H Add, v, p YELPho,e*q 'a.77` Z 33S <br />.5T Cantrador 1 v /yddr 1 C--t Y r �LQL�Phane,e16777-g10P <br />:dnsul=nt/Sub Ccnmacxor Address111Mfi Sf k C'tY�l ids_ thane �0~Y�•tJ 3�'S <br /> aiS Coordinates X Y .� Townsnro Range Sect= <br /> YORK TO BE PERFORMED <br /> 6I EIniVVELL i BORING(CPT GEO PROM kfYDROPUNtCH HAND-ANGER. OTHER-) �ESTRUGT�%)JVER-SORE choose rype below) <br /> I}SOIL BOR G a <br /> LL* GLS o W ,.ti `� Mme-S ur S`•t� <br /> t� . I PESSURE GRQUT <br /> OMMENTS It C1 PVD U C r WTII i r <br /> YPE OF WELL INST F TION TYPE CONSTRuen,ot4 SRE CATMW-S <br /> MONITORING HCLLOW STEM DLA.OF BORcHOLE " MULTIPLE CASJNGV 0 YES ONO WlwlrL C/LS1NG DIA' , <br /> EX CTION Q AIR NAMMEitI❑RfVEht CASING THICXNESS � TYPE OF CASrNG []S7EEL Opvc Q OTHER '`T� <br /> V !1 MUD ROYARY OEPTH OF GROUP SEAL , <br /> AIRSPARGETF7EM[E TYPE TO BE USED p AUGERS OSE <br /> Q RUSH POINT GROUT SEAL PUMPED Q Yes o (NOTE. MAXIMUM FREE-PALL DEPTH IS 30') <br /> SOIL BORING a HANO AUGER APPROX BORING DEPTH r � �CLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER OTHEP CONDUCTOR CASING PROPOSE ? {if YES list specifications here) <br />�MMENTS 91 se- 6 J <br /> IC �J <br /> NOTE: OF FS1 E 80RINGS REQ IRE AC SS OR ENCROACHMENT PERMfTS <br /> creby certify that I have preparea this aapl(catLon and that Te work will Oe,lone in aC=CU2nCt<witty San Joagurn County OrclinarlCB: State Laws and Rules <br /> I Regulations of oe San Jaaquut County Homeowner or Ncenstic 9genrs signature oeraruLS the fc1lovnng -I cerufy that rn the perfarmarrce of rhe wor-k <br />•wh,cA this permit is issued I:hull not employ persons sok=ra WORKERS'COMPENZATIQN L3w> of Callfcmia ' COntm=r's hrnng Cr sub- <br /> Ttmcting sugnature oerisfies following 'I cefbfy!hat h qk parformance of the work fprwhlch mis permlt.Es issued I srtaff employ perzons zw)sat to <br />?RKE'RS' NTP9IVSAT70 Lays of Crabjomra <br /> 4TAP LICANT MUST CALL.48 HRS IN ADVANCE FOR ALL REQUIRED INSPE� NS/ <br /> ned xLj <br />;EE SITE MAP 1N UNIT IV WORK PLAN DATED z /as/ate <br /> OI+PAFZrMEM7 USE ONLY <br /> yir©tron Accepted El ��ril�f Date Is:ued_ S;L� Areae <br /> ut Inspecuon By Date_ Final Inspection By Date <br /> Iruc=On InspeGron By Date <br /> MMMENTS l CONDITIONS <br /> TING ONLY AID* FAC* <br /> CCOES FEE INFO AMOUNT REMrrrED HEC CASH RECEIVED BY DATE PEEL%1 E-RVICE REQUEST NUM13ag INVOICE <br />�l O Q ~ co r /07 9 C G s/ l� c503ag I <br />,37 LICENSED co1 R ACTOR MUST SIGN LICENSE WOR E325' CQ'i QTS TTON DECI�?.A'T D�T <br /> T IV- b/23/99 /sign bkpg/hAI <br />