Laserfiche WebLink
02/26/2002 08:22 2094683433 <br /> FIFTH FLAOR PAGE 83 <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 /> (209) 463-3449 <br /> NOWREFUNDABL,E PERMIT E PIR S 9 YEAR FROM R&TJ ISSUED <br /> AppirGatwn Is hereby made to San Joaquin County for a permt to construct and/or install the work described This appCieation is nsade in compliance with <br /> San Joaquin Gounry Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Heafth Services,Environmental Health Division <br /> Assessors <br /> WELL Location 166 5 1%4,&e. M v� Cross Street Gsa(ymk S City o.I. ,n zip 9 eav- arcel# 3 T f O - ( <br /> 1c. �L 6 A. &eo <br /> PROPERTY Owner Address _ G .' Phoneo%6-714--22e6 <br /> C-57 Contractor WMA.4 rpt Address?0 %-9 ,�36 _ —city R.. V LJ_+ rk{,'Ryi2l , 71a�7! F+hor:est>�e7-3�r 1414a7 <br /> !IAA 14&G ,. . r .1 ., • e , ay�►�r{f <br /> Consultant)Sub contractor �w # _AddressJI40 id t+i..�.aDI'. 17o airy _Lu# '1l1 - Phosle#�t6-6$I-J� <br /> GIS Coordinates X Y Township. Range Section <br /> WORK TO 13P PERFO M D <br /> WNEW WELL I BORING(CPT,GEOPROBE,HYpROPUNCH,HAND•ALIGCR,OTHER') 1)DESTIRUCT10N(choose type below) <br /> Ij SOIL BORING# 13 OVER-BORE <br /> ' WEI1 '? <br /> # _-! 5 C i -7 ZA.9 Q •v'-S(4L.8) Q PRESSURE GROUT <br /> *Other'COMMENTS <br /> TYPE OF WELLNST LWTION TYPE CON5TRUC"fiON SPECIFI'CATi Ns � <br /> RTRACTIONWTORING W iCILLOW STEM DIA. OF SOREHOLF��MULTIPLE CASINGS?0 YES �h* vau CASING DIA:3&_0 AIR L-IAMMERMRMN CASING THICKNESSO TYPE OF CASING (j$TBEL I&= a OTHER. <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAI,_Z3' 0 S1rTRF-Mie TYPE To BE Usax 13 AUGERS ZgosE <br /> 4 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED jJKYes 13 No (NOTIr: MAXIMUM FREE-FALL bEPTH IS 301) <br /> a SOIL BORING U HAND AUGER APPROX BORING DEPTH JP 6Q' Dt JKBOLTED TRAFFIC BOX or (j STOVE PIPE <br /> (I OTHr=F;.— 1)OTHER T CONDUCTOR CASING PftOPQSEB?t_ QL(If YES,hst specifcatlans here); <br /> COMMENTS: , <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby oertkfy that I have prepared tons appimatvon and that the work will be done In accordance with San Joaquin County Ontlnances,State Laws.and Rules <br /> and Regulations of the San Joaquin County Homeowner or k ensed agent's sMnature certifies the follow}ng "1 cerft drat in the p&Hb mance of the work <br /> for which this permit is Issued,l shall not empfoy persons subject to WORKERS'COMPENSA?70AF Laws of t alrlbe hLp Coma's Meting er sub- <br /> contracting signature mom the f0gowmg, Y certify that In the performance of the waA for whk:h this permit is Issued f shall y persons subject to <br /> WORKERS'COM P ElY 770Nves Laof CaldorWa <br /> T Op ,lcCANt Ml�,�Sp'Gi4tT�d8;111fiOR�1NG ti"J, 14 ADVANCE FQ - <br /> Signed Title neor, No t Dales '�(�1 & <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: Voeev^6r �I1 zeal <br /> DEPARTMENT USE ONLY <br /> Applvcatlan Accepted By Date lmed ^" �" Are <br /> Grout Inspection By Date anal Inspectlon By oaten <br /> Destruction Inspection By Dater v , <br /> COMMENTS l CONDITIONS. <br /> ACCOUNTINQ ONLY AIR# <br /> PE CODES FBE INFO AMQrJNT REMITTED CHECK it REt;'>3 BY DATE P1rRMIT l SERVICE REQUEST# INVOICE <br /> � � $ 5I?V 3 ��- c^ S ATIT <br /> ? ED CQN'-RAICTQR WJST=SI0�Axy11N5E Be�QkxER,3 WimX1.0-4 _ ''ION <br /> ..irr ru_t/meq/qR/xian 6kooJMl <br />