Laserfiche WebLink
WEL_ DERMIT APPLICATION RM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> 2-13+1 <br /> + C S Assessor's (6-4-0-70•`Ct- <br /> WELL Location tN2_ ;7T,-eer— Cross Streets•(A0Fct-N;F, CityS'tTLi4TO t-1 Zip`jam 2-d(- Parcel#_ <br /> PROPERTY Own,Ier��� {1[. Litn4n CoAddress I�ib�ob4�ST•, tM , � City NAt ZipiIPhone# <br /> C-57 Contractor y*L0 DRILL NAddress IM � S(R6c"f City�au�Tb1J zip'1%4I Lic# Phone#916 4�7-�}top <br /> Ci 1L <br /> Consultant/Sub Contractor\poNt)Dp.6W4-til-ak1nbL� &A ddresjbr RANKWMT(:yt..SfE.T_city SN Lic# Phone#WI-23�-051g <br /> GIS Coordinates:X Y Township I Range CJG Section 2Z t Z3 <br /> WORK TO BE PERFORMED <br /> )<NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTS HER•) a DESTRUCTION(choose type below) <br /> %SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: 1'1t31.t_oLj S'TEIA ftv6g& <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING K'HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?0 YES )4NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS tJ A TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: $AUGERS XHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: <br /> JL 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' 5�i 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTHw 01 01 <br /> 0 OTHER: 1gOTHER�iPar &S kA CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS:T arff FfA-Zp,?_DM2L I g -C-r AN U I*Lt OW <br /> 511'm A L?eK. `$u^K-INt75 FDKZ Oti ttN6 LES 003 V694tq-NC-ai Mhos tO % S4QS7ALLi=D. <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 certify that in the performance of the work <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: `I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE AP LICAMUST CALL HRS IN ADVANCE FOR ALL REQUIRED INSPECTION . <br /> Signed x % Title CNS. t5QV,A4 0 _ Date Z4 0 3 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED kppL- <br /> II DEPARTMENT USE ONLY <br /> Application Accepted By Li�'Ls- C>1 i. __ Date Issued �-I Zg�� 3• Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> a`ld( I $<61,00 003_560"I' <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORItFRYCOMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />