Laserfiche WebLink
N � <br /> 9-22-1999 A 00PM FROM <br /> UNIT IV <br /> Fri 1- WELL PERMIT APPLICATION FORM „ ' jrfFF� , 7F, <br /> 04 AUG -4 PM I' 15 SAN JOAQUIN COUNTY PUBLIC HEALTH�� �cIC�S <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS- af') PH IIS <br /> 304 E. Weber, Third Floor, Stockton, CA , 952 <br /> 0 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> to construct <br /> This application Ls <br /> de in <br /> iance <br /> th <br /> Sanja qu is ountymade to San Development Tt equpn County Ch pter 9 111r15 permit <br /> and tthe Standardsnoflor install the work San Joaquin County Public Health Services,Environmental Hejalth Division <br /> San Joaquin CountyAssessor's <br /> Cct �.. d £p 952 parcel# Qj —OSR 32. <br /> WELL Location 85Q V t C 0v' 'Qo21.OL Cross Street > nz►a y O t � <br /> �!!. cxy SW,MKW-6 zip 9_5821 Phones: �� 369-2zso <br /> PROPERTY Owner Sr��:h+Per+N,ttnde Si �1Address 2349 Wau <br /> COY t�� Zip } U� 5l6 Phones# (9'��3 t 3-SEW <br /> C-57 Contractor IiV dress�O aLup+ <br /> RA/+_ rk�vts_ S� CIPhone# ?o1�93S- 5O <br /> Consultant I Sub Contractor CIM v Address 2� ty <br /> GiS Coordinates X Y <br /> Township Range Secuon <br /> WOR3C TO BE PERi'dRMED <br /> []DESTRUCTION(choose type below) <br /> EW WELL!BORING CPC G�OPR06E HYDROPl1NCH HAND-AUGER OTHER*) (I OVER-BONE <br /> SOIL BORING# Q PRESSURE GROUT <br /> WELL# <br /> 'Other <br /> C.^i0MENTS <br /> >= OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> N1TORING Q HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS YES Q NO WELL CASING DIA <br /> AIR LOW S HAMMER/DRIVEN CASING THICKNESS k�l/I. TYPE OF CASING U STEEL Q PVC a OTHER <br /> 3 EXTRACTION 11ll4jTRJ=MtE TYPE TO BE USED n AUGERS UHOSE <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL._ ` <br /> (j AIR SPARGE OVSH POINT GROUT SEAL PUMPED Yes ©No (NOTE: OA ED uRMAFF FREE-FALL BOX arDEPTH IS�STOVE PIPE <br /> O'� <br /> i <br /> �SOIt BORING a HAND AUGER APPROX BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? ND (If YES list speatScatwns here) <br /> a OTHER <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> rK will be done in tan) n State Laws and Rules <br /> I hereby cation th f he San Joaquin County thLs Ilcation and that the wo Homeowner or Umns d gent s signature Cert fess theordance tfoll folln J owing certify thain County Ot,n the erformance of the work <br /> foci Regulations o t <br /> for which th <br /> is feu e'cerissued,I shall t:Ges the fol ovoLng ` certify that rn he peftrmance of he Mork foroypersons subject to WORKMAN'S whichthis Permit!s slued alsh041 mmPlayontractor's hiring or persons sub/ect fo Su <br /> contracting q <br /> yvORKMAN S COMPENSATION LawS of Calrfom►a " <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIR1ED INSPECTIONS <br /> ftle _ <br /> Signed x yo <br /> e `� Date <br /> SEE SITE ;AIUINITI IV WORK PLAN DATEDEPARTNEENT!}SE ONLY ! �cDate Issued (� ref <br /> Application Accepted BDate <br /> D —Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> r <br /> COMMENTS I CONDITIONS r �-O I <br /> o f ' as- +a <br /> FAC <br /> ACCOUNTING ONLY A[Dit <br /> PE CODES FEE INFO AM1RCUNT REMITTED CHECK91CAS14 REC ED f3Y DATE PE <br /> RMITlSERVICE REQUEST NUMBER INVOICE <br /> 3 5D <br /> 3Z gs t 2 <br />