Laserfiche WebLink
09/15/9,9 IVSD 13:38 FAA 510 6;t,'1 6550 GEOMATRiX OAKLAND (g.004004 <br /> VV'r.�L PERMIT APPLICATION*-=ORM UNIT IV <br /> I OUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL"CH DIVISION (PHS-EHO) qQ <br /> S t P 1 7 1999304 E. Weber, Third Floor, Stockton, CA., 95202 �NIL <br /> (2091468 449 <br /> EW 4 `-' r :REFUNDABLE PERMIT EXPIRES 1 YEAR FROM CAT£ISSUED <br /> Application is R olp M t6 n�ol�� my for a permit to construct and/w install the work described. This application is made In compliance with <br /> San Joaquin County Cevela ment Title,Chapter 9-11 ISA and the Standards of San Joaquin County Public Hea)rh Services,Environmental Hcahh Division. <br /> 1881 LO A ust Rei• }r Ass"wes <br /> WE WLeratton Cross Street�'rn1 Cte1t.- City rYL Zlp 5 7 Pa cel#U2- Imo' <br /> PROPERTY Owner M-6 , g;, rn/' Address PA Box 1-7& City ' _Zip_ 537(o Phan.*aj-eH-0g1? <br /> C-57 Contra torp" 1i Address fr,,Edh � City ` k �Zi (tea �ir�s�v3fo3$? Phonc#��r 23?-�K75 <br /> Cornsultsntl Sub Contractor (IPo fAtl'11)( Add[e%,2M WIzWri{.trr„l4 Fl.-atyD� ELQ.+A UCO1 _Phoned JO' <br /> 7fa 3 j{JA7 <br /> GISCoor+dinates:K 311-70103 Y—!'Z1-Lj5fZ •,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 113ORING(CPT,GEOPROSE,HYDROPUNCH. HAND-AUGER,OTHER-) Q DE=STRUCTION(choose type below) <br /> y�SOL BORING I 81- B!ba OVER-BORE <br /> WELL 0 Q PRESSURE 43ROUT <br /> 'Other: <br /> COMfif£HiTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPF�gFICATIONS <br /> 13 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES U NO WELL CASING DtA: LA <br /> (I EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_ �_TYPE OF CASING: p STEEL ii PVG o OTHER:W_ <br /> n VAPOR Q MUD ROTARY DEPTH QF GROUT SEAL NA TREMIE TYPE TO BE USED: GAUGERS �tOSE <br /> QAIR SPARGE �PVSH POINT GROUT SEAL PUMPED: p Yes Q No (NOTE: MAXIi1RUM FREE-FALL DEPTH IS 30'1 <br /> �QtOiL BORING j]HAND AUGER APPROX BORING DEPTH ki j& - p BOLTED TRAFFIC 13OX or Q STOVE PIPE <br /> Q OTHER: R OTHER CONDUCTOR CASING PROPOSED? tjA-- (Il YES,Nat speclficatians here): AA <br /> COMMENTS: "L-16 5oi( one Xn linm zar lgyN h a mond ma:Lc rb," f jooriv+c, <br /> 'i I . I I IJ <br /> NOTE: -OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work MR be done In accordance with San Joaquin County Ordinances,Sta!ta Lam,and Ruts <br /> and Regtaatlons of Via San Joaquin County. Hamaowner ar licensed agent's signatura rorlifies the following:'1 coortify that to tho joenbrmeneo of tho work <br /> for w leh this permit Is Isatrod,I shall not wrrtpfcry persons sub)cct to MRXERS'CCWPENSA770M Laws of Ccilforrria." CantrZCWz hiring or sub- <br /> contracting signature cortlfiaa the fallowing-7 oer8ry that In the performance a/Phe wcfk for tvhkt this permff is tmed,1 sAef!employ parsons rL6j6d to <br /> WORKERS'CO SA"0 Laws QeNlbmla" <br /> THE APP UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x T1tk izQS GT t rin►�il ttZZD-to -;:I <br /> SEE ITE i1�iAP I ITT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY 9 <br /> RPpI. Accepted By Date Issued ArcaO� <br /> Grout Inspextion By Date Final lnspoction By <br /> Destrucrmn;nspectlon By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTIMG ONLY: AID# - FACd <br /> PE CODES FEE iillFO AMOUNT RERStTTEO CHECKp1CASH "— -TE <br /> PERMITlSERVICf=REQUEST tttlNtBER INVOICE <br /> - - <br /> UPAT rV-623M/sign bkpg/Ml '"" " <br />