Laserfiche WebLink
P%-;:RM <br /> UNIT IV <br /> WELLPERMIT APPi-ICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD�, _+ <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 ' <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE: <br /> �ilApplication is hereby made to Sari Jcaquin County for a permit to construct and/or install.the work described. This application is rade in compliance with <br /> San Joaquin County Deveicpment Title,C`apter 5-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental ssessor's Health Div0- 11 ion. <br /> {- 041 CJ` zi S�1 X Parc=-IT 635 31 1 l <br /> WELL Location��d �� �I"-' 4 ��� Cress Street = City 1�,�� p c, <br /> Il P_q- Cit S l`—+C�'1 Zip i� PhcneT � 377 <br /> PROPERTY Owner Address��� moo.. La'rC7�C+. `y 1'? - <br /> Address z3 LU Gity Sitxl zip ��U icTSI Phone 4CoSS7i Z <br /> C-57 Contractor_�1�C <br /> c.���3 �t?r0 7Sd '�sI�I I'tA(� S City C���v1Lic to F cneT 0 <br /> Consultant I Sub Contractor �Yb Q 7L_ _ <br /> GiS Coordinates:X - Y Tcwnship <br /> Rance 5ecticn_�g C�� <br /> WORK TO BE PERFORME2 <br /> 0 CSS i RUCTION (chccse:yPe.`,el--w) <br /> 0 NZW WELL I BORING (CPT,GEOPRC=_,FYJiOrtJNC 1, HAtiJ AUGcR,OTHER-) ' 0 CV R-cu=_= <br /> 0 SOIL BORING �1 ..ESS Fc GF,OUT <br /> 1l=LL 7 � r <br /> 'Other- <br /> Other kJ5 r1wC�, n'Lur7 tla� rx.rl yy. t7'' Mt R-0 ►-t_-eL u <br /> TYPE OF WELL INSTALLATION T'PE CONSTRUCTION SPE':IFJCATIONS <br /> �N10NSTDRING HOLLOW 5=-�1µ���f r�DIA-OF?ORE�'DLE MULTIPLE CASINGS?r Y=Si NO WELL CASiN^ <br /> 'j <br /> 0 EXTRACTION <br /> 0 AIR HANWERJCRIVEN CASING T' -S � 4d_NPE OF CASING: kr'tAvC OTI E.'. <br /> 0 VAPOR <br /> MUD ROTARY M DEPTH OF GROUT 5E4L S'I t`� TR=MIE TYPc i0 EE USED: AUGERS ;OSE <br /> AIR 0 PUSH POINT GROUT 5..=.L PUMPED: �Yest 0 No (NOTE: MAXIMUM FREE-FALL DEr'TH 1S 34 <br /> G Al `Tb 1fSDt 0 BOLTED TRa;�rlC SOX or STOVE PIPE <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> OTHER CONDUCTOR CASING PRO �c (if YES,list spec:ficaticns here}: +�D <br /> 0 QTH�R: 0 <br /> COMMENTS: (013c) (00, wa e-- PLar <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that I have prepared this applica[ien and that t,-,e work will be done in accordance with San Jcaquin County Ordinances, Stara La.+s, a.-Lc RU'les <br /> and Reculations of the San Joaquin Gounty. Horneowner or licensed agent's s,cr.ature certifies the following: "!cord i`y that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COh1P�NSA770N Laws of California." Cantracter's hirinc -,r su5- <br /> contracting signature certifies the fotlowinc: 'I certify that in the perer.nanc_of the wcrK for which this permit is issued, I shall employ persons sus?ec.to <br /> WOrKERS'COMPENSA T fON Laws of California.' <br /> HE APP 1CANT MUST CALL 48 WORKING HRS iN ADVANCE FOR_O [ALL REQUIRGL7 INS?ECTI��. <br /> Title 7 l5 Cates �� <br /> Signed x - <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: ,JWf_ X000 <br /> . PARTMENT U5E ONLY <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection;5y <br /> Date inalInspection y Date <br /> Gestruc len Inspection By Date <br /> COMMENTS I CONDITIONS: - S <br /> ACCOUNTING ONLY: I AIDS qr� <br /> F'=CODES FEE INFO AMOUNT REMITTED CHECK REC'Q BY DATE I PERMIT I SERVICE REQUEST# tNVOICE <br /> �Iq q .oc7 oto <br /> C-57 LICENSED CONTR.kCTOR MUST SIGN LI NS O ft5' COb12PE�N`"SAT/fIq.-21T LARATIO�T <br /> UNIT IV-6/23/99 /sign bkpg/MI � I <br />±g <br />