Laserfiche WebLink
i WEL _ PERMIT APPLICATION I Ikta, RM UNIT IV <br /> J`�calt�c SA�1q� JOAQUIN COUNTY PUBLIC HEALTH SERVICES D M NOT N <br /> Ftp gyp'• r(ENVIRONMENTAL HEALTH DIVISION (PHS= EHD) 1999 <br /> Nov s - <br /> 304 E. Weber, Third Floor, Stockton , CA. 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED By <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 /> _ _- Assessor's <br /> WELL Location 5105 S. £I Dorcwjo 5+. Cross StreetIVIV4�City S+ockIII Zip 95W(a Parcel# <br /> PROPERTY Owner (lnl Snmin-Tnnllt LLnCsL Address 9165 S . EI boradI CitySAGC_Ir3txnk ZIp 95ZAlo Phone# Lkkte 6324 <br /> C-57 Contractor IM , Address PO �k 51 Cit jLZi,i�71 Lic#Phone#��5 <br /> Consultant / Sub Contractor&\nr*r%&rc% Int. Address D0ecxL2,496 _ City %�'II llGLic# •(c►9___EIPhone# fg2S)83$� 1'lto3 <br /> GIS Coordinates: X., Y., Township 01 N Range ala E Section 23 t`4 lJ 24 <br /> WORK TO BE PERFORMED <br /> ii I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING # 3 0 OVER-BORE <br /> S WELL # Z 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? U YES 0 NO WELL CASING DIA: <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS OHOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> p OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> COMMENTS: <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 cern that in the performance of the work <br /> 9 q ty� 9 9 9: „ certify <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: "1 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 /> Ili Signed z Title Date <br /> SEEP fit Ulf IV WORK P N DATES : tg s,,,, ,,ar r, 199Cj <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 1�io G�� Date Issued //—i.J- —r f Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> , ems c . <br /> ACCOUNTING ONLY: AID# FACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT 1 SERVICE REQUEST # INVOICE <br /> ry ' Pl (e3 C -0 /f/i ?-& 02-// Y ` <br /> C-57 LICENSED CONTRACTOR MUST SIGN,LICENSE &WORKERS' CONTENSATION DECLARATION <br /> UNIT IV - 6/23/99 /sign bkpg/MI <br />