Laserfiche WebLink
i� <br /> 41 <br /> WELL PERMIT APPLICATION FORM`; - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE Coil �Po <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 12ij lk 6� <br /> 304 E . Weber, Third Floor, Stockton, CA. , 95202 Ti v/ 000 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r,�(,� <br /> Ipplication is hereby made to San Joaquin county for a permit to construct and/or install the work described. This application Is made in com�1'tanceywith <br /> ;an Joaquin County Development Title, Chapter 9-1115. 3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> / RAd 1 fly Assessors <br /> NELL Location <br /> ��5— Ld,tdA n +d Cross Street 4fildr/rin / City 144 Zip Parcel# <br /> 'ROPERTY Owner_FRnn &r:e �5�inx Lf�i AddressJ/�3.vilJ E. phr la-Ir�Ir,y d✓. City p,,HyQ, �' Zipy7r, Phone# 509 -Sit? - R.aL�� <br /> :•57 Contractory� 11/ ox lam, t TAsAddressp <br /> _ ! 1)G leey 5J City iR E Us �a Zip 94.57/ Lic# 2j2g tI Phone# %kL221-.4 � <br /> :onsultant / Sub Contractor � /OV�Iyf Cnu: RCma k1 ddrelAcir ,;,39 City {jy Lic# Phone# 71.,t)- ,2 y9- .K494 <br /> :IS Coordinates; X , Y., Township ;z $ Range 6 F Section / (o <br /> YORK TO BE PERFORMED - - <br /> rNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> p SOIL BORING # e 0 OVER-BORE <br /> B1 9J /Q <br /> -FE &kR if <br /> Other: � 11 PRESSURE GROUT <br /> :OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 4ON17ORING "-IOLLOW STEM DIA. OF BOREHOLE_ -_ MULTIPLE CASINGS? B YES JJ<O -- WELL CASING DIA' <br /> EXTRACTION 1` •r <br /> I TRACTION QAIR HAMMER/DRIVEN CASING THICKNESS SCI, <JO , JSHCf`` <br /> TYPE OF CASING: 0 STEEL rVC R OTHER : <br /> I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -� / TREMIE TYPE TO BE USED: p AUGERS &&TSE <br /> AIR. SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE:. MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH o?O > $f3OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: 0 OTHER _ CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> OMMENTS ; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work willbe in accordance with San Joaquin County Ordinances, State Laws, and Rules <br /> nd Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: ,al certify that in the performance of the work <br /> nr which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br /> intracting signature certifies the following; "I cerfity thatin the performance of the work for which this permit is issued, I shed employ persons subject to <br /> ✓ORKERS' COMPENSATION La sof California. " <br /> THE°APP�LICA� ItUSTUST CALLA8 WORKING HRS IN AbVANCE FOR ALLREQUIRED_. INSPECTIONS . <br /> ignetl x PV „(� �,(j"�(.f / Title 0. n r it of Date 3 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED : <br /> �f <br /> pplicalion Accepted By. DEPARTMENT USE ONLY <br /> �/� Date Issued Areav <br /> rout Inspection By Date Final Inspection By Date <br /> estruction Inspection By Dale <br /> OMMENTS / ION ea4V L� .{prx-y- <br /> wr'YZ, r1� <br /> ACCOUNTING ONLY: <br /> ?E CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT SERVICE REQUEST # iNVOICE <br /> 35--o / r? — Cl — a93 Co /- 7- o0 <br /> G5 sr.•;uc�lvs> ,b ca TtaA xaR MTJS r STAN T i�c��vs Iworti s' co�vinsNsnrzozv > cT axA loN <br /> NIT IV - 6/23/99 /sign bkpg/MI <br /> I , <br />