Laserfiche WebLink
Ulm./12/2t=1JtJ 11: :_'h 2U9463'd43 FIFTH FLI=ICR PAGiF 02 <br /> f ' <br /> WELL PERMIT APPLICATION FORM UNIT Iii <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (208) 468-3449 <br /> NOWREFUNDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> /,pp.icalion Is hereby mala to Sar.Joaquin Courcy for a permit t0 construct endior nsta'I the work descritad. This applicatior is m2de'n compliarco with San <br /> Josqui i County De,relopment Tile,Chapter 9.1115.?and the Standards o'Sal i.Icaq,in County Public Health Services,Environmental Hc:lth Division. <br /> / / �/ Assessor's <br /> WELL Location/�77 �YG6�lwr.c� �Cd cross 5:reet`tau:t{ La>YiiOT_?ip9r"o Parcell/98-�yv�G <br /> PROPERTY Ownery/? ' M.LYJr Addre551`1ac..li..� Ciry G7�ro Zip9.�?yPhcnz# � 195' ZS <br /> dooy77-7673 <br /> C•ET GonVactor4il i "�l� A.. Address/JVI —CIVIL Zip? `I.;Cx Phon6 <br /> Consull.ont 12Lib ContractOf r11e. fowGe.Grog/%L. Address/y�7 Ua.�(�+.d �y_Ci �� Q4 + Phone92 S 7S6 <-9 71) <br /> GiS Co.rdinbtes:X- 17-7r16 00 ,Y y7� 3�U Township 7Cr/yp2�lss _Range /S 6 ,Section 3 J <br /> WORK 1'D BE PCRI.ORMED: <br /> XNE*WEAL I BCRING(CPT,GEOPROBE,FYDROFUNCH,HAND-AUGER,OTHER-) p DES-RUCTiON([hoose type belcvo <br /> C SC!L BORING# 0 CIVER-BORE <br /> wEL'_tt p PRESSURE GPOUT <br /> "Other; <br /> CCh1P,tCN?S. Wc�rilo� S, SCtbsh /�i./Y �e.v-�-� J•�,.. ft./ G✓i>" GYfert.e,� la.,.. /,.1 /n�/va J <br /> rtPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y� <br /> ).tONITORiNG 0 HOLL00)STEM DIA.OF BCREHCLE /0 MULTIPLE CASINGS?C YES �0 VVELL C;AS;NG DIA; o� <br /> 0 FXTKA,TION )(AIR HAv1.%5ER/DRIVEN CASING THICKN ESS CLZ S T•!PE OF a CA.SIN 0 STEEL XPVC I)OTHER: <br /> 0 ,APGP, 0 MUC ROTARY DEPTH OF GROUT SEAL 70 TREMIE TYP=TO 9E U'S=D: fl AUGERS kDSE <br /> 0 AIR SPARGE a PUSH PONT GROUT SEAL PUMPED: )(Yes p N� (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SCIL BORING n HAND AUGEP. APPROX,EORING DEPTH ��S _ 0 3QLTED TRAFFIC BOX or XITOVE Pir= <br /> C DTHER: 0 OTHSR CONDUCTOR CA3IN0 PROPOSED? /70 (If YES,list spvciPcations hero)' <br /> COtr.t�SEtiTS: - — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby ce+lify that I have prepared this application and that the Nork will ce done in arr-ordanc_with San Joaaguln County Ordinances,State Laws.and Rui^s <br /> and legulatiors of th©San Joagjin:ounty. Homeowneir or;Icensed agent's signature cerlfizs tr1.:e fpllo ving:"I certify that in the performance el the work <br /> for which this perm+t is tissued,i shall not employ persons subject to WORKERS'COMI'PfiSAT1ON Laws of California." Contractor's hiring or 5un- <br /> m1cractirg signature cerifes the following:"I cer lfi that rn the peHormdnnp of the work for whfcti thrs perm,t i5 issued, i sh911 empwy pers0ns suaject to <br /> Li,C-RKERS' PE TlON taws of Califomia." <br /> C4,I- E UNIT I INSPE R 48 WORKING HRS IN ADV CE FOR ALL REQUIRED INSPECTIONS <br /> Signadx " Tilly/CcmpanyPriNamet Nae <br /> SITE FILE ADDRESS/WORK PLAN DATE: A;�2- 78,ZCJID -- <br /> DEPARTMENT USE ONLY <br /> Application Aocep:ed By �) t- Date Issues to, 1 S-no _ Area <br /> );rout Inspachon By Oat-±— Final Inspection By )Date <br /> Destrucucn Inspection By Date <br /> COMMENTS/CONDITIONS: CE l 4t�S2AC 1 NQS i�R C FFtL I`{ �a <br /> II ACCOUNTING ONLY; AlDlI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE RECUEST# INVOICE <br /> C-57 exp, t/ WC/waiver­ C-57 Letter DT Authorization to sign permit t/ _Encroachment doc(s). b/17/0C' <br />