Laserfiche WebLink
11/08!99 MON 14:5o_?t 0W918 858 0605 � � IT Corpora lon/]KC � 10002 <br /> 4 = INAL <br /> • D � <br /> WELL PERMIT APPLICA ION FORM U <br /> SAN JOAQUIN COUNTY PUBLIGHEALTH SERVICES FILE COP <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)463-3449 <br /> NDN-REFUNDABLE PERMIT EXPIRES 7 YEAR ROM DATE ISSUED <br /> gppliption is hereby made to San Joaquin County for a permit to construct andter instolt the ork desvlbed. This apprlcatian is made In compliance witty <br /> San Joaquin County Development Title.Chapter 9411and�standards at San Joaquin runty putrlic Health Services.En+r�rAs"sacra Health Division. <br /> rT r � �'a Io-og <br /> ,ftrtLL Locatler, lX ,r Coss [reef G Zip PartelaR <br /> AdL IC y �Y,�111C 1�_Zi¢ Phvrx 77�— a9 t u <br /> dress , <br /> PROPERTY Owner I <br /> U1I � /�T.) �Addres City ZiP LicAly on� Y� <br /> C-57 Contractor�� Arv[.►%iD ' <br /> Address 3 S rJdel t' CRY sof Pair <br /> Consultant ub ContracCor a cx o tom, <br /> GIS Coordinates:X <br /> Y <br /> Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION{choose type belowl <br /> fl NEW WELL,BORII+IG(CPT.GEQPROBE,HYDROPUNCH,HA C)AUGER,OTHER-) )KOVEFt-SORE <br /> 0 SOIL BORING to (]PRESSURE GROUT <br /> a WELL ax � <br /> -Other:_ to 11k 99 <br /> CommENTS: <br /> TYPE F L INSTALLATION TYPE LONSTFtUCTiOt159ECIFICATION <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE: M LT]PLE CASINGS?Q YES 0 NO WELL CA51NG DW <br /> TYPE OF CASING: 0 STEEL 0 PvC. Q OTHER: <br /> 0 <br /> EXTRACTION 11 AIR HAMMERlDRIVEN CASING THICKNESS TREMIE TYPE 70 BE USED: 0 AUGERS jJ1�OSE <br /> (�VAPOR a MUD ROTARY DEPTH OF GROUT SEALDEPTH 13 <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 yes a No INOTE: MAXIMUM <br /> TRAFFIC IRFE-FAoLEO STOVE PPE 01 <br /> 0 <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 <br /> OTHER: <br /> CONDUCTOR CASING PROPOSE (if YES,fist specifications here)' <br /> p OTHER <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the;ark;iU be done in Acca ance With San Joa1uin County t In thnr es.Stale laws.and Rules <br /> and Regulalion*of the Sen Joaquin County, tlorneowner or ticenaed agent's signature cc /Ties the following:«,certify that In The prfactoe »ce of the work <br /> 10�which chis permit is issued,!shelf riot employ persons aubleet to WORKERS'CO PENSATION Laws of Colifi mil" Contractor s hiring yr sub <br /> contracting signature certifies the following. f t�grtily Thar In the performance of the work la which this perrrrrl is issued,!shall employ pers[mS subjBGt to <br /> WORKERS'COMPENSATION Laws of Cafffotnl8." <br /> THEA PLIGAN'€MU$T,;Gl4l,1:48°1NbR}(ING' RS.4N'AbVa,_GE Q"F, x_11 B1R9 1REb: NS�E�TtON5. <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: /0 Z1hyL__ <br /> � <br /> / Area <br /> DEPARTMENT USE ON Y <br /> --;74( <br /> O <br /> /4 t7a Issued / / <br /> Application Accepted Sy <br /> Grout Inspection By date 1=i t Inipecd4n By <br /> oestrudien Inspectlan By Date /�� ar' 9 <br /> / - 9 <br /> COMMENTS,CONOITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK f REC'D BY DATE PEIiNI1T!SERVICE REQUEST* INVOICE <br /> 3 2. tib CID. 5Z, � 11.5.99 or� <br /> 02to <br /> C-57 L10EN'S9 CON'TR ACS�J t A LTS`I SIGH /CEN_ .-_-4R S'r 4iV P DECk AR A�!'ION <br />