Laserfiche WebLink
A <br /> UNIT' IV -� <br /> WE PERMIT APPLICATCON wAiRM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH-.SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) nr-SbEIVED <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 NGV 2 9 10 <br /> SAN iC AOUIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RUBUC HEALTH SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliai0tulfa�aieM�atlatMPlialRt�swith <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ <br /> a sormental <br /> Health Division. <br /> WELL Location.�T <br /> rJrn fJa��e:�._ /.)r/,rw�/lF Cross Street CCity Zip Parcel# <br /> ��• � - <br /> r7 Address ,SXJ) Ph`e <br /> PROPERTY Owner G �� r" r lR d tk'r Ilo7 City G �l Zip_�'l <br /> t" Y52 0S Z z <br /> S•�z k%, i � Lic#�8'o Phone# <br /> C-57 Contractor � Address 'c,5 N LA �f City P <br /> rat <br /> Consultant!Sub Contractor I Ir Address <br /> S S S, f Cty l_ic#L f l,l 'Ph�ne --i <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> fY <br /> WORK TO BE PERFORMED <br /> Q DESTRUCTION(choose type below) <br /> �IEW WELL!BORING(CPT,GEOPROBE,l{YDROPUNCW,NAND-AUGER, OTHER`) w- OVER-BORE <br /> SOIL BORING# i J PRESSURE GROUT <br /> 'Other: W T <br /> COMMENTS: i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA: -w <br /> [}MONiTOR1NG JU,R6LLOW STEM DIA.OF BOREHOLE V14 MULTIPLE CASINGS?U YES [j <br /> } a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE OF CASING: ©STEEL 14 PVC a OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL k SD TREMIE TYPE TO BE USED: AUGERS pHOSE <br /> VA SPARGE [J PUSH POINT. GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FRET=-FALL DEPTH IS 30') , <br /> y LTED TRAFFIC BOX or a STOVE PIPE <br /> g-AIHAND AUGER APPROX. BORING DEPTH Sib <br /> SOIL BORING Q it YES,list specifications here): 3. <br /> a OTHER:^���_n OTHER_ CONDUCTOR CASING PROPOSED. � <br /> COMMENTS: Cp <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS aws,and Rub,; <br /> In County 1 hereby certify that I have prepared this application and that the work will nances <br /> be done in accordance with 1 <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in.the performance of the wal <br /> certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> for which this permit is issued,t sha/I not ernploy persons subject to WORKERS'COMPENSATION Laws of California.' Contractors hiring or sub- <br /> contracting signature certifies the following: I c fy <br /> WORKERS'COMPENSA TION Laws of California <br /> T APDL C 1 <br /> US ,—­A C.' L 48.WORKING HRS �N ADVANCE FOR ALL REQUIRED,INSPECT „ . , <br /> Title 1✓ Date =2g` <br /> Signed x <br /> EE SITE MAP 1N NIT IV WORK PLAN DATED: <br /> S ARTMENT USE ONLY Area <br /> Date Issued._ <br /> Application Accepted ByDate <br /> i Date � ! inai Inspection By <br /> Grout Inspection By (Tates <br /> Destruction Inspection B +f <br /> COMMENTS I CONDITIONS, <br /> ACCOUNTING ONLY: AID# <br /> AMOUNT REMITTED CHECK# REC' Y DATE PERMIT/SERVICE REQUEST# 1NVOICI <br /> FEE INFO <br /> PE CODES <br /> CeLs f -� <br /> 35 'W E1vSATION=DEGLARAT` <br /> CENSER�CONTRPiC'I'ORMUST�SIGNaLi <br /> C-57-LI, . . <br /> UNIT IV-6/23/99 /sign bkpg/M1 <br />