Laserfiche WebLink
:).VICFS <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 ti 1999 <br />(209) 468-3449 x, HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P' <br />-WED <br />Lic# Phone# Consultant / Sub Contractor Address <br /> <br />City <br />GIS Coordinates: X Y Township Range Section <br />EOPROBE YDROPUNCH, HAND-AUGER, OTHER*) <br />G# BORI <br />EW WELL / BORING ( CPT, <br />0 O DESTRUCTION (choose type below) <br />O OVER-BORE <br />PRESSURE GROUT a WELL* <br />WELL. ?ERMIT APPLICATION ARM <br /> <br />UNIT IV <br /> <br />WELL Location <br /> <br />6457- dell7a,k7 c .Assessor's -7119(4,_Pe Cross Street City 5- 0 Zip 77S-2-C1-/Parcel# <br /> <br />PROPERTY Owner • a4,1--;•-1 7-°-'41-5-1-Address 7r4c .136/7 - City C-4-e---47J-1 Zip P3"-b*one# <br />C-57 ContractorM,VVCek 2'5D elsj 1C12)4c Abf(rti a/Meaty \-7(aj(41!) 5.-•(45C 617‘124?one# 96, 7 tee6 <br />WORK TO BE PERFORMED <br />*Other: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING U HOLLOW STEM <br /> <br />fl EXTRACTION U AIR HAMMER/DRIVEN <br /> <br />0 VAPOR UMUD ROTARY <br /> <br />_O AIR SPARGE POINT <br /> <br />OIL BORING ND AUGER <br /> <br />OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 (/1 MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: ['STEEL 0 PVC r] OTHER: <br />DEPTH OF GROUT SEAL 61-q...f . TREMIE TYPE TO BE USED: U AUGERS POSE <br />GROUT SEAL PUMPED: I] Yes 1] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') t 1:\ <br />APPROX. BORING DEPTH Fe155— I] BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />COMMENTS: l'W--127714 i)cle -&Ve7i)1 ciThi0140 .h--/ i f- N-(2Ac- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Ltt'W1-4/4ide - Title (.." Date A;Z/0 r? <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 1-2- 401 et C Area <br />Grout Inspection By (AirVVACe Date 1-21 I bh.C/ Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />"3-s-5 i 1M. 00 it csit oo \3 06'S g 1 -2A lo */- SR# 00.;---- ----------\,_ <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKE NSATIDYDEeLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI