Laserfiche WebLink
• - (�,0 <br /> ` 5�0 <br /> WELL PERMIT APPLICATION FORM UNIT IV S - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468.3449 <br /> NON-REF=UNDABLE PERMIT EXPIRES 1 YEAR FROM 1]ATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This application Is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-11 IS 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> Ap-� r� Assessors <br /> WI=LL Location 2-'3i4s Sq 5 �n� En I�'�a Cross Street City r s 1!/� Zip!S7(�7 Parti!fl-:2 Y?–07© rfl <br /> PROPERTY Omrner�0f e- 6`C1 " Address 2 S`T S• c n Fe ity_/i�fieA0 Ak ZiP±24 7 Phone##2` Y6Y Z6r3 <br /> _c <br /> C-67 Cantracwr 4k k 4Fuzrrul� p ddress3Z33 F,izScrs te) Vit Si !�6 _cii.,�i,..rJ..-1,�KZip 45'7 L Uc# jY ) 7 Phone#914 633 7z7G <br /> ty� <br /> Consultant!Sub Contractor f7d=C-0Z �N�c"'� "'wYt Address ,�kE��_� �^ !cv Ctty (or Llctl l02- Prone# <br /> GIS Coordinates X Y Township 35 'Al, Range_q 5rs* Section ��{ <br /> WORK TO BE PERFORMED <br /> OEw WELL BORING(CPT GlZEDBE,IiYOROPUNCu HAND-AUGER OTHER') 0 DESTRUCTION(elioose type below) <br /> 'SOIL BORING# U OVERBORE <br /> `,WELL# 0 PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )jWITORING WOLLOW STEM DIA OF HORf=iiOLE�' _ �MULTIPLE CA51NG57 0 YES ,�JO WELL CASING DLA 2r, <br /> RACTION G AIR HAMIAERfDrRMEN CASlAt.TH]CiCIVESSSLI L40 ,TYPE OF CASING p STEEL V FVC jj OTHER <br /> fl VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ! r TR£MIE TYPE TO BE USED XAUGERS VOSE <br /> 0 AIR SPARGE , 'USIi POINT GROUT SEAL PUMPED Yes Ij No JNOTE MAXIMUM FREE-FALL DEPTH IS 30'I <br /> %501LBORING j]HAND AUGER APPROX BORING DEPTH i SBOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER X11 OTHER CONDUCTOR CASING PROPOSED? AJO (If YES list speczfieatlons here) <br /> COMMENTS- • - -- ti <br /> NOTE: OFFSITE BORINGS RE IRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby Certify that I have prepared this apptrrabon and that the work will be done In accordance with San Joaquin County Ordmanaas State Later,and Rules <br /> and Regulation of the San Joaquin County Hvrnccwner or peened agents signature cemrires the following -1 certify#hat hm the Performance Of the work <br /> for winch this permit 1s issued.1 shall not erripfey persons SubJect to WORKERS*COuPtENSATION Laws of CarlfwW&" Contractor's hung or sub- <br /> contrachng signature cert4es the following -I coey ilial In the porformance of rho wank for which this permits issued.I shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cahfornra <br /> -CALlir ,I�ON` S[-'—�TOR_48}W.PPAP.�'''iTiR4`"111 ADVAIiIGE OR L.� E;QI?iRED; PP lO 1S+ <br /> S+grtedx --�zc� /� l Tttle/Company 5�lDlZ �n vutT:�+r+w �h,C pr+ <br /> PtintName�3G' ucln�crlrv4�e nate I-ID-04 <br /> DEPARTMENT DUSE ONLY <br /> �� ADO Area <br /> Appfecabon Accepted By Date Issued <br /> Grout Inspection By 06Date Final Inspecton By Date <br /> Destrucdon Inspection By Data <br /> COMMENTS/CONDITIONS <br /> OUNTING ONLY AtD# <br /> CODES FEE(NFO AMOUNT REMITTED CHECK 0 REWD SY I DATE PERMIT I SERVICE REQUEST# INVOICE <br /> D 231 ?• v 0023 <br /> 1/:8/2000 <br />