Laserfiche WebLink
i <br /> . i <br /> 1 ' <br /> WELL PERMIT APPLICATION FORM . UNIT IV <br /> §rl . a� <br /> SAN iuAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) FEB 2 2 2000 <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 VVIRCii ! 'i'v1Ehi IAL. HEALTH <br /> (209) 468-3449 EI <br /> NOM-R FUNDA6LE PERMIT EXPIRES ISSUED / S <br /> ERVICES <br /> i YEAR FROM DATE Iu <br /> l Application it; hereby made to San Joaquin Csaunly fora permit to [Onsimct antllor install Inn work desuiblic alth Sc NIC hon is mode int amealth a with <br /> San Joaquin Cuunty Development Tttte, Chapter 9-- 111, ..3 and the Stand�arddo of <br /> f.Sann-�Jvlfaquin Caeny Puhli�c�H�e�a�hth Service;,�Envl�roAffseenoes Health Division <br /> t `, StrcclLcu.fS.1�.C'tY • _a'{r7!£.,�•P_vlJ-Z'P �2.w�lnm'r-1"_ . <br /> WELL t-acetian <br /> pRQpgRTY Owner <br /> atv-SYa� ] zip 1 �Li� t I3 onr �' r c� ac t oQI <br /> C•57 Gontractor- FfDlltli't-,__F��>-{�J -Adtlress_ '�-�+�_7.1_LZtlaul.�l'-� — <br /> J fCI <br /> Addmss�[.� .s . EIY.lL-��-City L)t�'C.'a.K9Jc'# PhancA_r��" <br /> Consultant l Sub COntmctn[,_t_i t--� �-• — 5 <br /> Range � t Suction.. _.� a _ <br /> G19 C4erdlnatcs: X_ ,: Y_ _—, Tamship �rfd'1 9 <br /> WDRK TO OE PERFORMED <br /> ^N NFW WELL 1 B00.tN6 ( CPT. �-nFOPROBE HYOROPVNCH, RANO-AUGE2, OTHER'} DESTRUCTION (choose REypic Ixlow) <br /> - , U OVER-U9RE <br /> '45'OIL DORING a I. :3pr-'--C- •.5.� U PRE"URE GROUT <br /> U WELL k__ <br /> 'Other. <br /> COMMENTS: <br /> TYPE_OF: LL ' IN�STALLA7IQN TYPE CONSTRUCTION SPECIF17 AT` U`TIPLE CASINGS? p YES U NO WrLt CASING UIFI. . <br /> n MONITORING �y r1OLLOw sYE6r1 uIA. qF 60RFrtaLE_ _. <br /> U rXTRACTION l7 AIR HFlMMFR DRIVEN CASING F GROE i i . — TYPE TRFM F TYPE O BE USEUD V U AUGER-5 ()HOSE <br /> C1 VAPOR U MUD RO CARY GRODEp I OF GRGUM SEAL_ <br /> U AIR SPARGE U PUSH POUV I GRouT SEAL PUMPED. O Yes ❑" ��N��1a� {�N,Qr�TR MAXIMUM FREE-FALL DEPTH IS 301 } <br /> HAND AUGER APPROX. BORING DEP7H�,]i_�1W_.13 U BOLTLD TRAFFIC BOX or U STOVE PIPE <br /> Ip SUIL BORING U r o if yES, list ayseciNcations hero):,` <br /> 0OTmdR; —UOTHER_. CONDUCYORGAimIGPROPJSEU -�-� ( �— <br /> COMMENTS: — <br /> NOTE_ OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby testify [not I have red lhVn aPP is tion and that the Work will be done m accordance wdh San Joanuln County Orclinances, State Law: and Rules <br /> preps a <br /> and Regulations <br /> hlhfspOf the Safn iaavOdtt shalt nor em ypersons owner or svbpct to WORKERS COMPENSAYh0N Laws of Glrl rniar.% signature GIBItifins the 1011001791 "1 ceriffy that t;'h4'ontraaa shrn9fo sad ft work <br /> for cone acting a�gnabue cerbhee IIIA following: "I certify that in the "Prec"ance Of <br /> lire work lar which this PeI*nil is ksuetl, l than Ompl4y peracwa suhject to <br /> WORKEt?S' COMPEN3ATION Laws OfC3lrrvmia." <br /> CALL THE UNIT IV iNSPECTOR 44 WORKING HRS IN ADVANCE FOR ALL R1 QUIRED INSPECTIONS. <br /> /gyp• ,��f ly .[.'tcitn"� TltlefCmnpany_wflrTC <br /> Signed Ir-0 -,,te. `Ut---t`''t—Ni <br /> s Dat as L� « <br /> print Name .-, n-c�1 ' _ Y I tl�r, l1'1 <br /> 5E-E -VE IN UNIIr 'rJV WORK PLAN PATEDRATED g : �� - 99 <br /> DEPARTMENT USE ONLY 2 <br /> Date <br /> Application Accepted By �c�'` Dale, �3/ oQ_Final Inspection 69 <br /> Grout Inspectlon By •— __ <br /> Dale <br /> Oesbacinin Inspection 8y � - <br /> COMMENTSICONOITIONS=—_, � <br /> j ACCOUNYINO ONLY: AIDN If <br /> l <br /> Y DATE PE CODES FEE INFO AMOUNT REMITTEo CHECKi1 RECD BPERNifilSERVIdE REG1UF-ST INVOICE _ <br /> 3 1� Inu�zaoo <br /> 2 ' d U824f#kH60Z ' Out r -THpl U9110I 00 z Ctd_J <br />