Laserfiche WebLink
02/08/2002 13:58 2094683433 FIFTH FLOOR PACS 03 <br /> WELL PERMIT APPLICATION FOR T <br /> r 1�3E�d I fit`i�l���.�tl SERVICES <br /> EC <br /> PFPIT ���JJ� - SAN JOAQUIN COUNTY PUBLIC HEALTH S JAN 1 4 2002 <br /> _ ( a ( ENVIRONMENTAL HEALTH DIVISION (PHS-EHD] <br /> FEB 304 E. Weber, Third Floor, Stockton, CA., 9520bETTLER-RYAN INC.. <br /> (209) 468-3449 GENERAL CONTACTORS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> Application m hereby made to San Joaquin County for a permit to construct and/or install the work described Thls appl,catlon is mode b complienoe with <br /> San Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Servloes,Envt�ee sorsHeslth Division. <br /> WELL Location Mmai Cross StreetCoLlicer-y-W City 5 .&Jt Zip QS20Pamew -s •t`lo - <br /> aoos �, • <br /> �o. Sen Addrss 8 .GSC1tyE .6rowa Zlp S & honeS46w If <br /> 5 <br /> PROPERTY Owner a <br /> paR+e Vts dip 9401Lica�7ro "Phone# n q- ggyvo <br /> C-57 Contractor�l JuAard t�,1.1�g�Address aK 6 City., - <br /> D*.'416 CC".► dress j � d I�Citv�rrrl.nCir idf �'21t Phone#1+It -6ft-1300 <br /> Consultant!Sub Contractor <br /> GIS Coordinates Y- <br /> Township Ranged <br /> WORK TO BE PERFORMED <br /> HAND-AUGER.OTHERS Q DESTRUCTION(choose type belo v) <br /> �lEW WELL I BORING(CPT,GEOPROSE,HYOROPUNCH, a OVER-SORE <br /> 0 SOIL.BORING# G - G 1]PRESSURE GROUT <br /> #xLL g - <br /> •Other <br /> COMMENTS <br /> PE OF WELT. IN5TAt LATION TYPE CONSTRUCTION SPECIFICATIO <br /> TYS/f" <br /> ITORING J(HOLLOW STEM DIA.OF BOREHOLE---5-L—« MULTIPLE CASINGS? YES L 'VWELL CASING DIA. ,^ <br /> j IiACTfON AIR HAMMERIDRIVEN CASING THICKNESS �7CTA &10 TYPE OF CASING STEEL C 1]OTHER <br /> (]VAPOR B MUD ROTARY DEPTH OF GROUT SEAQ `1d TREMIE TYPE TO BE USED. AUGERS DIOSE <br /> - ',AIR SPARGE OZONE 0 PUSH POINT GROUT SEAL PUMPED D�� ijNOTE' TED TRAFFIAXIMUM C <br /> ALL DEPTH IS Or 1�STOVE PIPE <br /> S,, <br /> p SOIL BORING q HAND AUGER APPROX BORING Dir O 3<YES,list TRAFsPedc C BO ons here) <br /> 13 OTHER: 17 OTHER__. CONDUCTOR CASING PROPOSED?--&-0 <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;7th San Joaquin County OrGnances,State Lswe,and Rube <br /> and hereby <br /> cReguertify <br /> of the San Joaquin County Homeowner or licensed agents signature certifies the following-"!certify that!"the pwiorme"ce of the wark <br /> for welch this permit S Issued,f shall not employ persons subject to WORKERS'COMpENSA110M Laws of caffibmfa" Contra �ro <br /> contracting signature certifies the following i certify that in the perfom+arrca of the work for which this permit Is issued,!ahel!employ pe <br /> WORKERS'COMPENSAriON Laws of Callfornl&' , "' - <br /> :� <br /> 4 uw.�a <br /> SignedOb <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> � Date Issued <br /> Application Accepted. DAte��— <br /> Grout Inspection By pate Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS; <br /> IC'CiOUNTING ONLY AJ DO FEE INFO AMOUNT REMITTED CHECK 0 REC'D BY DATE PERMIT I SERVICE REQUESTSINVOKE <br /> 51X 7V <br /> 55 <br /> UNIT IV-6/23/99/sign bkpg/Ml <br />