Laserfiche WebLink
11/06/2000 11 15 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES !! 170 <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> Appliasbon iS hereby made to San Joaquin Caunty for a permit to construcz ardor install the work described This apfl4tabon is made in compliance with <br /> 53n Joaquin County Development Title Chapter 9-1135 3 and the Standards of San Joaquin County Psstil,C Heatth Sennas, EnvWronrriental Health Division <br /> WELL Locatlon`(M W tj;�r_kAMh � Cross Street VhS A.City .K-1 __-�p Assesssors <br /> _ <br /> PROPERTY Owner ++:`Din LLCAaa:ere P�. �ID 2oq`� eay�aUSbh z,p77232 Pnone5 S1 S- 306 <br /> S <br /> 'I% Zip91FST3 L-,#s S115 Phonedr(llS)31 49100 <br /> C.57 Con,ractar,�� 4t'1I—�__Addresx �------- <br /> Ga. k� 1 a1 _AdcressZ'70 $tO- _\)NS S1` City Senn„.g Lice Phone> 7e7��35 ''1'QS0 <br /> Consultant Sub Contractor _ <br /> GIS Coardinales X Tewnship Range Section— <br /> WORX TO BE PERFORMED <br /> ,' NEW WELL r BORING(CPT GEOPR06E HYDROPUNCH HAND-AUGER OTHER-) a DESTRUCTION(choose type oe3ow) <br /> a SOIL BORING# OVER-BORE <br /> 0 WELL 9 MW6 W7�M�Q Q PREs'SURE GROUT <br /> 'Other <br /> CCMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS Lf It <br /> fTORING "OLLOW STEM DIA.OF 13OREHOLEI It,MULTIPLE CASINGS' a YES VVO WELL CASING OIA <br /> EXTRACTION a AIR HAMMERJORIVEN CASING THICKNESS Sc1n.4d TYPE OF cAsiNG Q STEEL XaVC a OT1-fee <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL— 50 ' TREIA[Fz TYPE 70 BE USED CI AUGERS 0HOSF_ <br /> a AIR SPARGE a PUSH POINT GROUT SF-AL PUMPED XYes a No (NOTE MAXIMUM FREIE-FALL DEPTH IS 30') <br /> a SOIL BORING D HAND AUGER APPROX BORING DEPTH — t BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 3 OTHER CONDUCTOR CASING PRCPOSE07 C if YES, list saeeifications here) <br /> COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> I hereby 09rtrty that I have prepared this application and that the wank will be done in accordance with San Jo3ouin County Ordin3nc&s State Laws and Rites <br /> an.1 Regufations of the San Joaquin County Homeowner or licensed agents signature certifies the failowm9 "I cvrury ihas.n rhv Performance of the work <br /> for which this permit is issued 1 shall not employ persons subject to WORKMAN S COMPENSATION L,aWS of cahlorms" Contrac.aCs hiring or sub- <br /> contracting Signature cerbrtes the fallowing 'I Certify Mar m rhe performance of the work for welch this permit is issued 1 Strad Ampfoy persons suo)ect to <br /> vvoRKMAN S COMPENSATION Laws of Calrfomra ' <br /> TH APPLIRANT MUST CALL 48 FIRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS / <br /> Signed xaAkL �itle4. C Date l �� <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED 10/23/00 <br /> DEPARTMENT USE ONLY �[ <br /> Appticwton Accepted By1 _ __ Date issue <br /> o Area LDP d 7 <br /> Grout Inspection By Date Finai Inspection y Date <br /> Oe±tructien Insoectton By Dste e <br /> COMrAENTS/CONDITIONS �M et-"I W� 7 $ <br /> FAC4 <br /> ACCOUNTING ONLY AIDS <br /> pE CODES FEE INFO AMCUNT REMITTED CHECKSICASH RECEIVED BY DATE PERMITISERVICC REQUEST NUMBER INVOICE <br /> I <br />