Laserfiche WebLink
' 12/06/2002 14 57 2094663433 FIFTH FLDDR PAGE 03 <br /> i <br /> 1 <br /> • <br /> WELL PERMIT APPLICATION FORM SITE <br /> t <br /> S MITIGATION <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT N <br /> ENVIRONMENTAL HFALTH DIVISION (PH$-EHD) <br /> 304 1~_Weber, Tbird Floor, Stockton, CA,, 95202 <br />' (209) 4683449 <br /> KION-REFUNOABLE PERMIT EXEIRl=S.IYEARFRONS DATE_i MUT-0 <br /> AppR=tiorz is hereby made tb San Joaquin County far a permit to construct andlcr install the,aeark described This 201=t,arz Is made 10 corrTpE,ance W1t1,San <br /> Jaaq=CoLmV Development lWa,Chapter 41 l!5 3 and the Standards of San JwgLk Gr uniy Pubitc Health Sem0as PlrrArorimental HeWO 1 nvLgan <br /> Awa Bar's <br /> WELL Loca►.io �S�3 1 rRrF v a Cress Street f4d7a ,¢tib �C:ty r mex-n v zip_?s'zrs FarcoW f l 9�fy4�31; <br /> I'i20Pl:RTY�wnarRPZRr+ rc'��r t./Z1-saoI Address 2.23 f yxAGTil 17h. C1kyFAsr Jt4u�.airu pyo <br /> - <br /> C 5rcontractor kJ�Stl�rw.c.�r r,,,�Actdress 33 ����.,�r fc�_,�ql• 5re- , Ls' �:�o� f6 656-7316 L?02 <br /> CorrsaltarttlSub Contraator AIG A ?-6? Addrsss, q67�4 /if�FS.vP�a +�e�ILy51Jv J al ?Phoned :b)S6+P-f�r{9z <br />' Gts toortllnates%-f z r si3 _,Y 3�4T�s{ TownshipRan= SeeLon <br /> WORI{74 ,PET2FOR141E�, DESTRUCTION(choose type belavv) <br />' i?qFW VVELL I BORING(CRT,GSOE-ROBE HYDROPVNCH.HAND-AUda:.t3TFtFR R a OVSR43ORE <br /> 1I SOIL BORING#^ n ppZSSURE GROUT <br /> 'ocheWELL n f7s✓' M L�- GCout Spacmcaaorts <br /> r , <br /> h1IIVTENT$' G7>�i= $�T t�T-Gt >�iPdl cS�o .✓EL LaGooT .✓ IcLa_ Cw d - f��poS� wcLc <br /> TYPE INS7ALLATTow TYPE CON T UQTION gacimpaTIONs <br /> I MoNiTCRING 9 N4OLLOW STEMdIA Cfi BCFiF.314i-1 Id?n"u MULTIPLE CASINGS?D� I NO WELL CASING DIA <br /> EEL <br /> PVC <br /> 0 EXTRACTION p AIR HAMMER/f]RiVEN CASING THICKNESS t " p c rr�B Tr CAS 7YFE 7078E USK �A THER 11 HOSE n VAPOR n MUD NOTARY Dgp-r"t Op GRooT SEAL3 <br /> En' alas <br /> ,I No (NOTE MAXIML3M FREE-FALL la1=PTi� IS 30') <br /> j AIR SPARGE 13 PUSH POINT GROUT SEAL PLIMPE <br /> 0 501L SORLNG li HAND ANGER GROUT S�20IFIGATIONS <br />' it t>THEFL [}O'T'HER APPROX BORING DEPTH BOLTED TRAFFIC BOX or LI STOVE PRE <br /> CONDUCTOR CASING PROPOSED?_C if YE;U,list 5p0z3tteatiana Item) <br /> Yt,f+� 7-WO <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE NET IV INSPECTOR 48 WORKING HOURS IN A13VANCE I^OR AC.L REQUIRED INSPECTIONS. <br />' 1 hereby certify that 1 have Prepared this application and that the work wilt be darn in accordanoe with San JoAquin <br /> County Ordinances, Rule Ogul2tions,anti all applicable Cai,fornia State Laws <br /> J�� TitiFlCornprhy ��Gca •Sr1111!!!.1 1.4 <br /> Slgrtad <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT FV FILE,ADDRESS: <br /> WORK PLAN DATE-D' <br /> Oatalssaeei �"r!o Ad <br /> 17 <br /> ApApplication�,r�PtGd BY -. '- LOate_ <br /> Graut impelct,on ay Dade ><raai lospechnn By <br /> Desiructia�7 Insaee6cn>3Y Date <br /> COMMENTS I comDmcms <br /> AGrw.OtlNt T ANG ONLY ALD# c ^+ <br /> DES FEE ti<!rr n AlllJOUN i FtEMITi BT7 GNECK# REC'D SY DATE PERMIT 1 SERVICE REWES 4 <br /> PE COINYO[C� <br /> f �s j g1_ � s � �. f 62— 0030 <br /> C-57 _-57 La ter of r4ujhor'izat.an* sign pertsttt_encroachment dcc 9� X00 <br />