Laserfiche WebLink
11/0612 1 15 111y4bbJ41J rtr- trl 1"LUUrc r-"Qc U <br /> Project No <br /> )3$� �%�ELL PERMIT APPLICATION FORM UNIT IV <br /> r <br /> I*_1PF_1 BF----&�W JOAQU(N COUNTY PUBLIC HEALTH SERVICES Ta' <br /> V• !� <br /> 1 2 ✓ 4 5 6 EN�lIRONMENTAZ HEALTH DIVISION ("PHS-EHD") IC <br /> //J <br /> X04 E Weber, Third Floor, Stockton, CA", 95202 <br /> (209) 468-3450 <br /> NON REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> App4cabon is hereby made to San oaquen County for a pernvt to cormtru=and/or Install rhe work described This awllc3tran rS made rn compliance with <br /> San Joaquin Covoty Development Title Chapter s-i I i S 3 and the Standards of San Joaawn County Public Health.S'eN1ca5,Env,ronrner%al Health Drv,Ston <br /> Assessors <br /> WEI,LLocattono" Wtw -k�p�{Wb',,, L-q�.WQ' CmssSireet !k1k V%hSA-C+IY CKl Lp Parcel <br /> L- LI~C P 2©°tg Cay Rale, bh z,n77X32 Paan 5 S9) 4 S-8306 <br /> Pad?ERTY Owntr y 1Dht Address �- <br /> C-57 Con,ractor c�Q DY111 1 Address Ok% w�p_ C,ty 2 Zip9411 L,cy 415 S 16S Phoned gIS]3(3 41200 <br /> ,C-767)g35. Z) <br /> Cansuitant Sub Contractor <br /> `p Adcress 2c) f tY'kl'.S St' Crty,S� 1.41 L'Ce Phone <br /> GIS Coordinates X Township Range Section <br /> WORK TO BE PERFORMED <br /> ,` NEW WELL I BORING(CPT GF-OPROBE HYDROPUNCH HAND-AUGER OTHER-) a DESTFtUCTtON(choose type oelow) <br /> 0 SOIL BORING it 0 OVER-BORE <br /> 0 WELL#nuf6 okw-7 (AW a PRESSURE GROUT <br /> "Qrhpf <br /> CC.MMENTS <br /> TYPE,OF WELL CONSTRUCTIt)r11'YPfc CONSTRUCTION SPECIRCATIONSrt <br /> NITORING '4MOLLOW STEM OtA.OF 30REHOLE 10"I MULTIPLE CASINGS-7 p YES ;IO WELL CASING DIA 4 <br /> FRACTION AIR HAMMERJORIvEN CASING THICKNESS5c\_L-t0 —TYPE OF CASING 0 STEEL )<PVC Q OTHER <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL^' SD TRE%41E TYPE TO SE USF-0 []AUGERS (INOSE <br /> a AIR SPARGE p PUSH POINT GROUT"SEAL PUMPED Yes 0 Na (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER APPROX, 80RING DEPTH ~ BOLTED TRAFFIC SOX or Q STOVE PIPE <br /> 0 OTHER COKDUCTOR CASING PRCPOSI=D7 (If YES, 'Is(specificonons here) <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have Prepared;hits appticanon ana tn3tme work wal be done&n accordance wrtn San JogQurn Counly Ordrn3ncts State Laws and Rules <br /> and Regulations of the San Joapuut County Homeowner of t,censed agents signature certifies the following f csrsrly Yhafrn ilia perFonnoncs o/the walk <br /> for whreh this permit rs sssued,l shall not amploy persons subject to WORKMAN S COMPENSATION Laws of Califorma-' Contr3c:ors hlnng or sub- <br /> conttaettng Signature certlfr8s The following, 'l certify Mat in the Porformavice Of the uroflt for which this permit is issued l shall Ampfoy persons sun)sct tv <br /> Vv0RKMAN S COMPENSA77ON Laws of Calrforma <br /> J. TH APPLI NT MUST CAl1 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> srgrle[I x_Qf <br /> SEE SITE MAP 1N UNIT IV WORKPLAN DATED 1a/�-3160 <br /> DEPARTMENT USE ONLY <br /> Apptic3tron Accepted By - Date Issued ea s 0� <br /> Grout Inspectran By Oare Final Inspecuon y Date <br /> Destructlen tnspecrlon BY Date <br /> If <br /> COMMENTS/CONDITIONS I rn S� - 3 CL".f" <br /> FAC2 <br /> OUNTING ONLY AIDS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK-VCASH RECEIVED BY I DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 602-q <br />