Laserfiche WebLink
pplication Accepted By <br />rout Inspection By Date <br />estructiOn Inspection By <br />OMMENTS / CONDITIONS: 76Ve)/ <br />Date <br />Date Issued <br />Final Inspection By <br />COMM <br />UNIT IV 2iaito <br />ORIGINAL <br />05/04/2000 13:38 <br /> <br />2094671118 AGE STOCKTON <br /> PAGE 02/02 <br />WELL PERMIT APPLICATION FORM <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 />ot1.2p;k4ilies <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 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 9.1115.3 apd the Standards of San <br />r1 <br />Joaquin County Public Health Services, Environmental Health Division. <br />Covn4-41 R;C7 clE mort 91 - 10.A. , Assessor's it 6F 1/8.7 <br />WELL Location LW. lol-et5 teal on 'Zaps{o L Cross Street co 5forr City (.--40 Zip Parcel* cbriS '32 P <br />PROPERTY Owner FASt CIT.f.. 4ov10 n Address (ti VZ/ C.A19171!3(.- 40. City LI:1P Zip CISM-Phone#,(2...447 9$3 <br />Address 323.3 FI*4-2,e ) s4-. City IC364:ati:G. Zip951tit.Lic#5P-/971 Phone# 12/ ten 77-710 C-57 Contractor WE.* 4 Al- A1.04- <br />Address "1 ØQ5 . Ify 05.1(\ City STccleizn Lic# 1184t1. Phone# Z&l b7 -log b Consultant / Sub Contractor G . <br />GIS Coordinates: X Y Township 3 f\J Range AC E Section <br />WORK TO BE PERFORMED <br />. <br />cfiEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # OVER-BORE <br />"KWELL # IA/ 1;) a PRESSURE GROUT <br />*Other; <br />ans4-0/10,ian ct,P- <br />COMMENTS: NO-) -Ltv-€.1 W Z_11 C..4-6r0 <br />fYPE OF WELL INSTALLATION TYPE <br />r,viONITORING S,-IOLLOW STEM <br />] EXTRACTION a IR HAMMER/DRIVEN <br />]VAPOR OMUD ROTARY <br />] AIR SPARGE j] PUSH POINT <br />] SOIL BORING 0 HAND AUGER <br />] OTHER' 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE $ ;eta. MULTIPLE CASINGS'? D YES 0 WELL CASING DIA: <br />CASING THICKNESS Sc.610/t TYPE OF CASING: I] S EEL U PVC a OTHER! lichte./ <br />DEPTH OF GROUT SEAL /4) TREMIE TYPE TO BE USED: ,)5UGERS OHOSE <br />GROUT SEAL PUMPED: Xees D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3(Y) <br />APPROX. BORING DEPTH ISO *BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N a ( if YES, list specifications here): <br />;OMMENTS: • <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />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 />id 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 />Dr which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />ontracting signatUre certifies the following: -1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />VORKEPS COMPENSATION Laws of California," <br />ALL THE UNIT IV INSPECTOR 48 WORKING HRS IN A ANCE FOR ALL REQUIRED INSPECTIONS. D <br />Areib <br />D <br />ACCOUNTING ONLY; AID# <br />_FAC# N, <br />'E CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - . - : •_UEST INVOICE <br />M,L2/....,.....024 /3621_24 R#002,z <br /> -- 1/18/2000 <br />igned x <br />rint Name -77 "U.cV8. 114 pate OSA& p <br />SE SIA IN yvFLyz .,A0:1w0gA.NLO0 <br />DEPARTMENT USE ONLY <br />„I <br />Title/Cornpany &SEAT Geo/ L.57” / ( ACK() <br />1 <br />‘.vo dc pion Aa4Z_WPI,Y.^‘ „AAR/ zs itith Zafe) ci