Laserfiche WebLink
RECE'lVEED) <br /> WELL PERMIT APPLICATION FORM c#-;E <br /> JAN 3 Q ZQQZ SAN OAQUIN COUNTY PUBLIC HEALTH SERVICES �11lMGA T IOi� <br /> UNIT fV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HE,�i q 304 E. Weber, Third Floor, Stockton, CA, 95202 Ufni I--- — <br /> PERMIT/SERVICES (209) 458-3449 - <br /> NON-REFUNDABLE PEFZ A T EXPIRES i YEAR FROM DATE ISSt3E33 <br /> ppfir ation is Hereby made to San Joagcun County for a permit to const uat and/or ir:statt the work described. This apc6cabon is made irr=mpirancs with San <br /> mgsnn County Development Title C:sapter9-1115 3 and the Standards of San Joaquin Caurity Puobr-Health Services,E==menmt Huff=Division. <br /> {�'� Assessor's �s <br /> �L Lacatiar OD - 59.44..E IGo-,4z) Cross Street F-P�fi.y9 -r ;nppd Parcef" � oD��h <br /> RCFERTY Owner Adder 200) ¢ -c � I clay '�( La 77�{_'jp_ 1Z _pi an <br /> .-57Cantractar U- DbIIL4C Adder vo S l,J,�7T r <br /> .orrsuitartt)Sub Cantrac nr � fUl a�1�Adore ti� Ali/ c, iratl � U �ZZ Phonefl - A-06 <br /> AS Coordinates.X Y Township Range SectQn <br /> VOR ERFQRMEt?- <br /> W BORING 4 CF3",GEOPRCeE,HYDROPUNC�4,1 LAND-AUGER,CTfiF-=r) [I 1DE51 RUCTION (choose type be-Jow) <br /> IL BORING []OVER-BORE <br /> KW' LLEp PRESSURE GROU i <br /> Other Grout Speafimdo= <br /> ;OMMENTS <br /> - PE OF WE3.L INSTALLATION TYPE =NSTRUCTION SPEMF?CA-n0NS 01 <br /> NI <br /> I MOTORING OL LOW STEM DIA-OF HOREHOLE�X� 4�MULTIPLE CASINGS' I YES 0 NO WE CASING UiR <br />] G I]ON AlRHAMMESUDRIVEN CASING TFiiCKNE5_ TYPE OF CASING: U STEL PVC U 0717 R <br /> r []MUD ROTARY OF-FTH OF GROUT SEAL &gLi� . ,i REMIE TYPE TO HE USED-"XAUGERS [I HOSE <br /> SPARGE l]PUSH POINT GROUT SEAL PUMPED AYes II No (NOT-E. M UM FR E-FAL-L DEPTH IS 30'} <br />] SOIL BORING []NANO AUGER GROUT SPECIFtCA710NS_ � a TIS -7- 6E1A&1 L - <br /> OTH 4"Cr4ER Ar P ROX $f]RlNG 0-E-T-NS VOLT--D TRAF?C SGX or {]STOVE PIPE <br /> CONDUG T OR CASINGPf2OAOSc]s 7 (if YES,list spea$cattons he--e) <br /> r,ammE rs DQE SiVA-rye- t�At at f <br /> NOTE: OFFSITE BORINGS R&QUIRE ACCESS OR ENCROACHMENT PER MITS- <br /> CALL THE UNIT IV INSPECTOR 4S WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that l have pre red this application and that the work will be done in accardance with Sari Joaquln <br /> rus ty dlfl n U and Regulations, and all applicable Califamia State Laws. <br />�[gned x � - 'L_ TibelCornplly 51I Lr ! � AIu�sctl fl-i� <br />'fust Name c.L �� Cif Date��/DEPARTMENT USE USE ONLY <br /> SITE MAP IN UNIF IV FILE, ADDRESS: !�G'd �/�u� /� �'�-•- G4f� <br /> WORK PLAN DAT ESD: ?-7 4) <br /> apticabon A=pted By gate[ssaed "0 Z- Area Q g <br /> rout Inspection By Dato Final lnrspecbon By Date <br /> esbucbon Inspection By Data <br /> IS 7 CONDITIONS <br /> ttNTTNG ONLY. A104 <br />'E CL]OES FIE INFO Al9i OUNT IZENIrrTE7 CHECK# REC'D 8Y DATE r _ PERNrfT if SERVICE F2MUEST ir ILSF1fOIG1= <br />-7 1 1 � ��� `� 9/27IOO <br /> /- D <br /> WCC WAZVER C-57Le-+ r of Authorization t a .sign permtt Encroachment doc <br />