Laserfiche WebLink
e4/28/2000 08: 23 20946694 FIFTH FLOOR • PAGE 03 <br /> �p WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEf�� E DOPY° <br /> ENVIRONMENTAL HEALTH DIVISION A., 95202 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4664449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County tar a permit to construct andior 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 /> } Aers <br /> WELLLocation 23505 S Fe "•CrossSheet City -„t""-Ak <br /> p95360Parcel,42-`rr-070-0II <br /> PROPERTY Owner SVAn Phone#L?%0 838- 7503 <br /> C-67 Contractor Wi L IaAz M:.1' Address 3233 F,fz9c,:1d Rd $r-6 CityZ+w.le(vd«., Zip 9S74z Lic#Ssy9r97 Phone#YLG 63E-7z72 <br /> Consultant)Sub Contractor S c1:0¢ Address VI-) k,7,w,� rZ.l a•'1c 1A CIryZ1cln(-4-11 Llc#6LOZ Phone#91L 8/z115g171 <br /> GIS Coordinates:% .Y .Township 31 c Range Q P+""r Section 21 - <br /> WORK TO BE PERFORMED <br /> bg'NEW WELL BORING(CPT, EOPROSE,HYDROPUNCH.HAND-AUGER,C�R') 0 DESTRUCTION(choose type below) <br /> WCC��s OILSORING# Sfl DOVER-BORE <br /> 41NELL# f4 W-5 W d 0 PRESSURE GROUT <br /> •Other. Pio nn} is 42,2 An:-. <br /> COMMENTS / eJe.ep bor.'s 64 aintet= 2 Wr-ds 6 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� <br /> MONITORING7�GAIR <br /> OLLOW STEM �> DIA,OF BOREHOLE S�„ MULTIPLE CASING57 a YES_JO WELLCASING DIA: <br /> 0 EXTRACTION HAMMER DRIVEN CASING THICKNESS fL1+/(f1Q TY'PE OF CASING: 0 STEEL 'PVC 0 OTHER: <br /> 0 VAPOR UD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: VAUGERS $HOSE <br /> AIR SPARGEUSH POINT GROUT SEAL PUMPED:)CYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> gSOILBORING 0 HAND AUGER APPROX.BORING DEPTH "W" t3Sr BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: B OTHER (CONDUCTOR CASING PROPOSED? -/0 (if YES,list specifications here): <br /> COMMENTS: • 2- 2- = ,r; 'fro -7!; ' L".--(c v r fo <br /> I <br /> r — +0 01 s c.1-.SSG = e ds' -4j <br /> NOTE: OFFSITE BORINGS RE UIRE 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- Homcowner or licensed egenfs signature certifies,the following: -1 certify drat in the puWrmance of the work <br /> for which this permit la issued•f shell not employpemns sWect to WORKERS'COUPENSA710N Laws of Californla." Contractor's hiring or sub- <br /> Contracting signature certifies the following:-1 certify Malin the poffomtance of the work for which this permit is issued.I shell employparsons su*ct to <br /> WORKERS'COMPENSATION.Laws of California <br /> ObE ,jp{ U,kFfjkS-ti" ;48.1WAk [N01Ti S'IN'ADY1NItiEEIFOR�LLZRE;AIRED IM,�PE�i&lpk(S5 <br /> Signetl><,Af7r yG r'�, Tlfle/Company Seco k- 7-n-(C.rna�7�n a(, 21nC <br /> Print Name -aW /-ve h4r 1pwe Date -7-1d-00 p <br /> tl <br /> DEPARTMENT USE ONLY 7�3 U G Area C7�o8' <br /> AppGcatian Aceapted By Date Issued C, r <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> EACCOUNTING ONLY: AID# <br /> FEEINFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT(SERVICE REQUEST k INVOICE <br /> � Iol2z 3 Z 39 <br /> 1/18/2000 <br />