Laserfiche WebLink
V. tL� PERMIT APPLICATION r}RM UNIT IV <br /> SAI4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PH , �" 1 V E D <br /> 304 E. Weber, Third Floor, Stockton, CA., 9 22 <br /> (209) 468-3450 J U L 2 3 1999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE lyUED <br /> ONMENTAL HEALTH <br /> ,application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thia�RMIdn ts >�deu Ytjcdrr�lfance with <br /> San Joaquin County Development Tdle,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> A)0_ Assessor's <br /> WELL Location �U S• i NC d Iw Ave . Cross Street So Yt DtY <br /> o hIU1Ce�'Y�� �J <br /> PROPERTY Owner,a P�� 5itMcil �t 3 ��Q jZAddress A"DD mQl ��tp Clty QDC�' ,,) Zip 4Q iq Phone#,V-llfq'2�d <br /> }ou.NLK&eot 7n&;,,r 7"It f-e 3S iS�,J1,,�las+� ��c. 5><t l l 7�i Zip ��lyUccg Phone# <br /> C-57 Contram r Address <br /> riddress4MSI�-1IL6V1uC1tSyIC) LL� Phone#, -clibrl-ID06 <br /> ConsultantlSub Contractor QNQ1 ! h IA ? K <br /> GIS Coordinates:X_ Y Township Range Section <br /> WORK TO BE PERFORMED <br /> lEW WELL GRIN (CPT GEOPRFIRING <br /> HYDROPUNCH. HAND-AUGEFR OTHER`) 0 DESTRUCTION(Choose type below) <br /> 0 z ::Z—�g _ 0 OVER-BORE <br /> 0 WELL: 114 0 PRESSURE GROUT <br /> -Other <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ©HOLLOW STEM DIA Or BOREHOLE—-2�� MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMEWDRIVEN CASING T HICKNESS­4 r TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA!_ l r l DFO46_7 REMIE TYPE TO BE USED:. a AUGERS clHOSE <br /> }AIR SPARGE GUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH (5 /- 2 D Q BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPIOSED? (if YES, lis specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> nereby Certify that I have prepares this application and that the wont will tie cone in accordance with San Joaquin County Ordinances, State Laws, and Ruses <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature4 certifies the following: "I certify that in the performance of the work <br /> Mr which this permit is issued.1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiriq or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomi'a.' <br /> THE APPLICANT MUST C 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. n <br /> Signed xTiL� Title " «7 vCifa is Date �02 007 <br /> SEE SITE MAP IN UNIT IV WORK PIAN. DATED - L�-� 99 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By� a.:.,: 17 Date Issued 7— 1 Area C7 S <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# T <br /> PE CODES FEE INFO AMOUNT REM(7TED HEKCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER ` INVOICE <br /> � 50� y � f� I l�S�`r Gv 71z� d 7 ! _ <br /> UN17 of-5/99/Mr <br />