Laserfiche WebLink
C o NIT IV <br /> WELL PERMIT APPLICATION FURM <br /> SAIF JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD")<i,, <br /> 304 E. Web4r, Third Floor, Stockton, CA., 95202 AF��p2� <br /> (209) 468-3450 ��sF�T OOD <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR ;:ROM OAS ISSUE} ��C�9lT <br /> r. <br /> made to San Joaquin County�for a permit to construct an install the work desc ibed This application is made ntal pliance with <br /> Application is hereby <br /> San Joaquin County Development Tdfe Chapter 91115.3 and the Standards of San Joaquin County Public Health Services, cnvrr�sessa�s earth Division. <br /> II ! u ran Parcel# <br /> WELL Location ,Cross Street t �T t C ty L <br /> j d , ���LL Phone# Lits -Z`EL� 2 <br /> r^ 5 t TV`t tG�t Address �� 7,� City fI ` C 7 7�'Y rc U <br /> PROPERTY Owners r CJ Gtr' Lo Ci - <br /> Contra= V �v�tlt Address 4J�} G Ciry,4Sfr Zip ^��`t J4'0� ?honear 7f� <br /> C-57.Ontrat;or r <br /> —772zc <br /> Phone: .-3L- : <br /> Consultant I Sc5 COr•.tramcr <br /> 4r 'A"t 1i Address <br /> ' v 1l Tdvmship Range Section <br /> G+S Coordinates:X <br /> 'NCRK TO BE PERFORMED <br /> ESTRUCTION (enoose type betow) <br /> 3 vEW WELL 1 BORING(CPT, GEOPROBF HYDROPUNC`l,HAND-AUGER.OTHER') r' *9v=R-BORE <br /> ar'}}SOIL BORING":, Q PRESSURE GROUT <br /> L{ "'E1,ti J T: i <br /> j; <br /> 'Other'. it <br /> COMMENTS: <br /> 7-pE OF WELL CONSTRUCTION i YPE CONSTRUCTION SPECIFICA 71ONS t <br /> VO 'fit! CIA: <br /> -4MCNITORING 1r"I`HOL1_OW ST EM DIA.OF BOREHOLE 10 -- MULT iPlri::.SINGS?n !ES %AS{NG � <br /> (� Q L OTHER <br /> �=X RAG'SON I�AIR!iAMMERIQREVEN 'C�iSING;HtCKTtES5 SPE OF CASING: S E=ti 4� <br /> VAPOR 3 MUD ROTARY DEPTH OF GROUT SEAL 54 V(aGC- ,,REMiE TYPE TO 9E USED: 3 AUGERS GCSE <br /> 3 AIR SPARGE 3 PUSH POINT GROUT SEALPUMPED: 4Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH ES 30') <br /> 1 SOIL JOKING 3 HAND AUGER APPROX. 3CRING DEPTH 3 BOLT-Z0 TRAr'rIC BOX or a STOVE?IPE <br /> =NOUCTOR CASING PROPOSED')—.r.f YES,ii5.specifications here): <br /> ] OTHER: if <br /> COMMENTS: <br /> I l <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? I <br /> i ;.1ereoy certify that i have prepared this aoolicatiiin ana that the worx will oe aone,n accarcance with San Joaquin County Ordinances. State Laws, and Rules <br /> and Regulations of the San Joaquin County. Ho neowner or licensed agents signature certifies the feliowing: "I certify that in the performance of the work <br /> for which this permit is issued, i shall not employ persons sunject to WORKMAN'S COMPENSA7701Y Caws of California." Contractor's hiring or sub- <br /> ;Ontracting signature certifies the tollowtng- 'r ce Ir&y that in zhe;DerTomkV=Ol me mcrx for wnic.'7 47is'7emrtr is L=ed. 1 Snail emDfgy per-ons-L'C,'eLt rD . <br /> ivCRKMAIV'S COMPENSAT70N Laws of^ lifomraj <br /> r <br /> TH A PI...ICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> !r 11 ++ 1 1 <br /> —�.. �I i lite �-t 7��L✓1 - l.l.�-C_ flare. <br /> Signed x ✓�' r <br /> �E <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> /� I! Areae <br /> apaiication Accepted fay_ C �� l�iDate Issued <br /> Grout Inspection By <br /> }t Da1e F=inal Inspection By Cate. <br /> Destruction Insoection 3y ✓y� <br /> I' Date <br /> COMMENTS f CONDITIONS: 'I <br /> AID# �' <br /> fl I =ACS <br /> .,C..OtJNi1NG ONLY. 3f . <br /> �CO�ES FEc INFO I AMOUNT REMiTTrD I CHEC CASH RECEIVED B- ---T DA,c i PERNItT1SERVIGE REQUO T NUMBER INVOIC: <br /> S - 7 3 7 <br /> 3 v <br /> UNI-. TV- 5/99/MT <br />