Laserfiche WebLink
11/08/99 MON 14:50 FAX 916 858 05 IT Corpora ion/RC 2002 <br /> J- 1 <br /> WELL PERMIT APPLICA ION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESFIL� �� <br /> ENVIRONMENTAL HEALTH DTVI ION (PHS»EHD) <br /> 304 E. Weber, Third Floor, Stock n, CA., 95202 <br /> (209)458-3448 <br /> HON-REFUNDABLE PERtVItT EXPIRE51 YEA FR0M RATE SUED <br /> Appifatian!s hereby made t6 San Joaquin Cvu»ty for a permit to construct and/or instett the ric deavibed.ISThis 8ppllcation is made In complianr a with <br /> San Joaquin County Development Title.Chaplet, <br /> 9.1 116 nntl h Standards of son Joagvirn County Public ttsalth Services.Env>rAsseasors eatth Division- <br /> 1T Cross tmet C Zip Par o� Qted$ <br /> vYELL Location ,,`` �� <br /> Address 114 cityW ei741s11<`&"Zip Phv 77 - 9q f <br /> PROPERTY t7wner ¢� (p W-7__ _ ` - <br /> Addres ty hanell [!J 1Q <br /> Ci <br /> at Lid► <br /> CM57 Cordractor <br /> Ftione9Y ����� ' <br /> IIII-� QeA�h- Address 3 S n}�t 1 City ALicll <br /> Cartsultant utr Contractor T (�c7�P__ o-4'S I <br /> GIS Coordinates:XY <br /> To.rnshiF Range_ _ Section <br /> WORK TO 8E pirRFORM6D <br /> DESTRUCTION(choose type below) <br /> NEW wELL/BORING(CPT.GEOPROOE,HYDROPUNCH.HAND-AUGER,OTHER) IXOyER-SORE <br /> 0 SOIL$ORINCIP p PRESSURE GROUT <br /> fl WELL# <br /> -other:_ 19 <br /> COMMENTS: <br /> 7YFE INSTALLATwN TYPE GONSTRIICTION SPECIFICATIO 5 YES N WELL CASING DIA. <br /> Q PE OFO F- Q HOLLgW STEM DL9L OF BOREHOLE M LTIPLE CASINGS D CI O <br /> TYPE OF CASING: (I STEEL II.PVC 0 OTHER: <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TRLMIE TYPE TO BE USED Q AUGERS BKOSE <br /> Q VAPOR MUD ROTARY DEPTH OF GROUT SEALDEPTH IS <br /> — <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes I]No INOTE: MT&'MUM o RA FC E-EFALorL4 STOVE P PE 0') <br /> Q SOIL BORING p BAND AUGER APPROX.BORING DEPTH <br /> p OTHE10. <br /> OTHER— <br /> COMMENTS: CONDUCTOR CASING PROPOS (it YES,list spe�cilwations here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> State Laws.and I hereby reftlfy that I have prepared this application and that the work will be done in acca ance with Sal Tature cc rtifLeS the ow&Count o117 rdi nae�rfarfia�of the warps <br /> and R"ulations of the Sen Joaquin County. Homevw lrsorrS suti ct to WORxVFZS,C UPENSATION Laws of Ca Ifornla," Contractor's hiring or sub- <br /> fur which this permit Is issued,I shall not employ P I <br /> contracting signsivre certifies the ratlawing:'i car*Milt In the parl5rmarrce of the work f r which this permit is issued.!Shari employ Persons su6jecf t0 <br /> WORKERS'COMPENSATION Laws of Caulom)a." <br /> T�E'A P ICAN€Mt3 Ty;GE+iLL-48 WOR <br /> ING iRS:.��.AbV.,.NCEFp ; ( L 13EDUIREb 1NSPEC EONS. <br /> Tr1Ie .� DPW 1��� <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLA DATED: <br /> 1 0 <br /> i DIEVARTMENT USE vto Issued LY <br /> Area <br /> Accepted 8y Oates,Date �F­ <br /> Application l Inspection By <br /> Grout tnepe* on By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDtTiONS, <br /> ACCOUNTING ONLY: ADO <br /> P8 CODES FEE INFO AMOUNT REMITTED CHECK* RRE�TCr'D- BY DATE pEf;MIT 1 SERVICEREQUESTS INVOICE <br /> 3� �� 5Z G�►t.K ��•S'�9 �Zld <br /> 2 <br /> G57 I;ICEl�TS' ''C�NfiRA t :'lv iJ:S 'SIG$:'�CEN_� _ OR ON PE1'1S"A�fION DECI:ARATION <br />