Laserfiche WebLink
FFM WILLIAM DUBOVSKYp!'/ y`f FILE <br /> 'SIRON ENTAL PHONE NO. : 408 253 1 r-' �iia-- n�ff <br /> WELL PERMIT APPLICATION FORM'. UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAUCH DIVI$IOj'f•(PW91EA6) VQRAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209r 459.3449 <br /> NON-RCFUItDA�L!P_ P, MIS 1 YEAR FRQ ATE SU[D <br /> Application is hereby made to San Joaquin County for a pwYM to oonatroot andibr instaa die woes deserib.e. This spplleaticn is mads in compliance with <br /> San Joaquin County Development TAM,Chapter 6-1116.3 and the Standards of San Joaquin County Public Health Services,ErvaonmMfal Healtlt Division. <br /> Asseseora <br /> WELL LotaB0l1 2373 Mariposa Road CresastreetFurmingtotty Stockton 2p 95201 Para6►1]1/300/09 <br /> PRopildITMownM,HKyky Crane �Addny 2373 Meripona R�ity Stockton =IP95201phon«alF300)f�-37 <br /> CStContnGor $live Driltinu Addr.aa104% Wpale St- _ CityRaar pzn-0_Ayjige 6040#Lne (ti50)322-285 <br /> Consultant/Sub Contractor WDF AroresaP_O_ )Inv 99 cry E' ratios 65006EhonMi,S(143 <br /> rls Ceedinates:X__ .Y Township flange Secdon <br /> WORK TO 41 PERFORMED '--.. —..• .—.. -. <br /> x a NEW WELL)BORING(CPT,GEOPROBE,HYD H. HAND-AUGER,OTHER`) D DESTRUCTION(ohm"type below) <br /> ALU.BORING A- l), l , ._, <br /> p PRESSURE GROUT <br /> COAAMENYS: <br /> TA N TYPi <br /> - CONSTRUCTION a D MONITORING 3O*W Il WPWEM DIA,OF BOREHOLE MULY IPLE CASINOS?DYES ONO WELL CASINO DIA: _ <br /> a EXTRACTION D AIR MAMMERIDRIVEN CASING THICKNESS TYPE Or CASING D STEEL D PVC D OTHER <br /> *- <br /> 11 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS OHOSE <br /> Q AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> B nft% MG D HAND AUGER APPROX.BORING DEPTM_ D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER:_ IT OTHER CONDXJCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby have prepared this appagtMn are that the wore will be done In scoordance with San Joaquin County Ordinances.SOW Leas.ant Rules <br /> and Raputabons of the San Joaquin County. Homeowner or aeensed agent's signature cerolles the following: It cardly Over In the performance of the work <br /> for which MA permit is issusq I~not employ parsons subject to WORK®44'COMPENSATION Laws or California." Conhador's hiring or sub- <br /> conyaOWp agnature CYISIIes the fallowing:-/"duty that In the perMrmanco of the work Por which this permit is Issued.I shei employ persons subject to <br /> V#URXERS'COMPENarION L.ews ofCaifbmia.' <br /> E APPLICANT UST CAIS{ NRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> sq - Tao f97 &1kF,,, DsM 7/21/99 <br /> SEE SITE IN UN T IV WORK PLAN DATED 7/30/99 <br /> DEPARTMENT USE ONLY �7 <br /> Application Aonsplee By �7_ Dste Issued / ' 2.7.99 Ars 06 <br /> Grout Inspection By Gate_ Final Inspection By <br /> DeWudion IngBy OMs <br /> COMMENTS I CONDITIONS: .5 / <br /> /Ya T <br /> ACCOUNTING ONLY: AIDS FACS <br /> Ps COORS FEE 9W0 AMOUNT REMITTED CHECKWOASH RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOIC <br /> . . . _. <br /> w�' mac . .. . ._... ..... .. ...` �� ..... <br /> .I <br /> UNrT IY-6/23/99/sign bkpg/MI <br /> —77— <br />