Laserfiche WebLink
0//24/2000 15:48 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN .JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (20S) 458-3449 <br /> NOH-REFUNpABLE PERMIT EXPMCS T YFAR FROM OAT ISSUED <br /> Application is hereby made to San Joaquin County ror a permit to ConsauC an0fnr install the work described 'This anplics;iorl is merle in ccmpliance with <br /> San Joaquin County Development Title.Chapter 9-11 15.3 and the Stanoaros of S-art Joaquin County Public Health Services.Env'ieonmental Health Division <br /> WELL Location n 7 f �a J7 /?I ayY Sl Assessor's <br /> Cross Street 0" ,$�Gk� <br /> City zip 5��/ Parceta�G`r-G I <br /> PROPERTY.OwneLlvtr <br /> A' MC-z a(e Tfi)} 5 00 <br /> r Address_ (� 3 L G C:ty,_.C�,ZipT—<- Phoney R7a 7 <br /> C-57 ContraCtOr�� ' Address FF 3'� r'�+�-+ CitySaay'"++1�zip G.r1 �P 2G�G <br /> -)Phone 207 796 J111' <br /> Consultant lkeb. Q (3t. ......�� Adorers p0b C ty�wvw►-rl 1��J3 Z�Pnane#.�� Sp��7 <br /> GIS Coordinates:X 12 7 ,Y 'f Or'b Townsn,P / N Range 7 S <br /> ectfon <br /> WORK TO BE PERFORMED <br /> %NEW WELL/BORING(CPT.GEOPROB8.HYDROPUNCH.HANO•AUGER. OTHER-) <br /> 0 SOIL BORING X d DESTRUCTION fehoose type below) <br /> XWELL a 3 p OVER•eORE <br /> 'Other; 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING gHOLLOW STEM DIA.OF aOREHOLE--E-~ MULTIPLE CASINGS?a YES )?u0 WELL CASING OW n <br /> 0 EXTRACTION p AIR HAMMEWDRIVEN CASING THICKNESS 1e.1 r/d TYPE OF CASING: 0 STEEL PVC <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T.REMIE TYPE-`I Q OTHER. <br /> OHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 'OSE USED 0 AUGERS IS 30 <br /> Q SOIL f30R[NG Q HANG AUGER APPROX,GORING Dt_PTk 2SNQ�OT1r' MAXIMUM FRES-FALL DEPTH!S 30) <br /> BOL`=0 TRAFFIC BOX or: 0 STOVE PIPE <br /> 0 <br /> OTHER:_a OTHER CONDUCTOR CASING PROPOSED? <br /> I it YES,list specd,caGons here}; <br /> .TENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> nereoy cettify that I have prepared this application and that the worK w1I1 Ce none in accordance with San Joaquin C3unty Ordinances,State Laws.and Rules <br /> Ind Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the-allowing. "l certify that in the performance or the wary <br /> or which this permit is rssaad.t shaft not employpefsons sub/oer to WORKERS'COMPENSATION Laws of Cafifor>tla." Contractors hiring or sub- <br /> VIORKting signature SA TI 6 the following:Ca li miaCellt' (tzar in tyre penbrmance of the.Ncrk for which t7+i$permjr is issued.1 shall employ persons suajecf:o <br /> 'VORxEr7S'COMAENSaTION Caws o/Calr/omia ' <br /> TII A !ICAfVT MIST CQ!L a�HIRS I,V�AIOVrNCE FOR ALL=ate <br /> INSPECTIONS. <br /> ;fgrled x <br /> Title 7 � <br /> SEE ITE MAP IN UNIT lv WORK LAN DATED <br /> DEPARTMENT US Y <br /> pplication Accepted By _ Dare Issuea 7 0 <br /> rout Inspection 8y —Area c')741. <br /> Date Find Inspection By Date <br /> estruuion Inspeetlon i3 Date <br /> OMMENTS/ ONDITIONS: &ICZ�t /ytGJ s - - 20 ,�.,�4V k <br /> aL44 e-� <br /> ACCOUNTINVZIEMI'"IED <br /> FACx <br /> }E CODES INFOjASH RECEIVED aY DaTE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 35-01 00-i.3 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS'COMPENSATION DECLARATION <br /> 4IT EV-6/23/99/sign bkpg/ME- <br /> I <br />