Laserfiche WebLink
10-18-1999 2:02PMM P. 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIG� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHDbE� 2 O <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 2000 <br /> (209) 468-3449 ENVIRONMEiU i HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ERMIT/SEM/ICES <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 Tide,Chapter 9.1115.3 and the Standards of San Joaquin County Pudic Hearth Servloes, Environmental Health Division. <br /> ���y.25)`)00 C/rA.1S.rL ,-y.9 Assessors <br /> WELLLocation MCTr'-t`Y r eYVI Cross <br /> ,S.�trreeeet y 7 City zip Jila Parcex <br /> PROPERTY Owner{'TIAL 1377`tS r l�yl�'1LSddress City ZIP`�24Phoneit <br /> C-57 Contractor I/1 e1/ Q A%�. City Zip Lic# Phonero <br /> Consultant l Sub Contractor Address �6. `i.old /44?/;4ciry l icr/— Pnonea 9�b-362-�r332 <br /> GIS Coordinates:X_ Y ;Township oV Range_ Section 3-4� <br /> WRtK TO BE PERFORMED \ / <br /> 0 NEW VVELLI BORING(CPT,-GEOPROBE,HYDROPUNCH,RANO-AUGER,OTHER-) /VEST UC (choose type lI W) <br /> D SOIL BORING ant /` VER-BOR <br /> 'Other. ILN. OWE O* / RESSUREGROUT rJ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ry <br /> D MONITORING 1�0 <br /> LLOW STEM DIA OF BOREHOLE_ MULTIPLE CASINGS?a YES 70 WELL CASING OtA:� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL\PvC 0 OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO SE USED: 0 AUGERS OHOSE <br /> p AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `a SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH 99'--ZO O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> BOTHER: O 694Vq OTHER` CONDUCTOR CASING PROPOSED?_ l/11M (if YES.list specifications here): j <br /> COMMENTS: /� /'p J 4/'G Q2/ ,/ / ;-, 70 <br /> ! TeTr- <br /> NOTE.- OFFSITE BORINGS REQUIRE ACCESS OR NCROACHMENT PERMITS <br /> 1 hereby certify that 1 have prepared this application and that the wort 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,l shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certily fhf in the performance of the work for which this pen if is issuad, 1 shall employ p y persons subject to <br /> "ORKERS'COA196MATION Laws o/Cak e.' <br /> LI US r WORKING HRS IN ADVANCE FOR ALL REQUIRED INSP�-n9NS- <br /> i J/ <br /> Signed x ". .. Tide/S j` Oate <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> '��I/' _ pDEPARTMENT USE ONLY <br /> Application Aocepted Sy Ak,,,D'� n/ Date issued /2 -1 IOC Area G 5 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction inspection By Date - <br /> COMMENTS I CONDITIONS:_[t/_al CZ r'M �r <br /> ACCOUNTING ONLY: AIDM <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK rt RECD BY DATE PERMIT/SERVICE REQUEST Oil <br /> INVOICE <br /> zq'e2 (,b- (.o" 1XV70t <br /> AIP I z7 ncSR#60ZMqz7 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORXERS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />