Laserfiche WebLink
05/01/2002 14:03 2094583433 FIFTH FLOOF 5011 .0r-'k .- 5011 -0 3 E p_ <br /> 1-1 <br /> WELL PERMIT APPLICATION FORM UNIT 1V <br /> SAN JOAQ.UIN COUNTY PUSLIC HEALTH SERVICES _ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 t' <br /> (209p 488-3449 <br /> - r - <br /> QN-REFLINDABLE PERMrT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 1s heraby made to San Joaquin County for o permit to construct andlgr install the work described. This application is made in cornpNance wi <br /> San Joaquin County Development Title, Chapter 9-1115.3 and she Standards of San Joaquin County Public Health Services, Environmental Health ❑irviE <br /> 5�6Q I Assessor's <br /> WELL LaGat}on a, CrgSs Street ►nI 33 City Y E� 1►i5 Zip 9 .� Parcel#Asti• alp_ <br /> ii r _ <br /> PRCPERTY OwnerArn-lei s*eC,n Re11;.-,. Address��tQ L.f.17•+-Figr.� er Rd- <br /> 4 <br /> G,S7 Convector t$ r•1�,+t <br /> Co. Address 1:sQ aW fc { }_ ^_City± a"i;-+ems 2ip`�"�55� Lim�a�ldarPhenaR etc 3 L3- 5 <br /> onsulka L 1 Sub GantraGtar '7eo�ra}T�" Cl.-s..lIim-WA Address atal kftl: + 0� S+. Cityv2�� Lic* SL°-C <br /> -L a+.. FJadR - Phandlc <br /> C93-t4- <br /> Coordinates:X Y Township Range Section <br /> — <br /> WORK TO BE PERFORMED <br /> NEW VVRL 1 BORING CPT, GEQPROBC, HYPROPUNCH.HAND-AUGER.OTHER'] DES7RUGTtdN[ti7Agse i]rpa belt <br /> QSOIL BORING S S@1 -� i-SR3-10. rah- Il, S13. I SG- l3 QOVER-BORE <br /> -Othe <br /> d WELL# �D'PRESSURE GRO <br /> r �\ <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS + _ <br /> Q MONITORING X14MLOW STEAK DiA,OF BOREHOLE 6 ;el. MULTIPLE CASINGS?]]YES ANO WELL CASING DIA: N <br /> Q EXTRACTION Q AIR RAMMEPiDRIVEN CASING THICKNE55 9J1� TYPE OF CASING: Q ST!n/t;__L 111 PUC Q OTHER: <br /> o VAPOR 1] MUD ROTARY ❑EPTI-i aF GRQLJT SF=A1-4�J 1 L bads�VUI TREMIE TYPE TO BE USED: POUGERS+Wo <br /> Q AIR SPARGE [I PUSH POINT GROUT SEAL PLIMPED: )tr'es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS,3 <br /> %SOIL BORING [I HAND ALJGEFL APPROX.BORING DEPTH to* -- G ' 13 BOLTED TRAFFIC SOX or [ISTAVE PIPE <br /> Q OTHER: (]OTHER CONDUCTOR CASING PROPOSUD7, JAAC (if YE�S.list specifications herel: <br /> COMMENTS- �iI S 62r ' ! it dori <br /> . ey�► Li IJ,— aI4 <br /> 1A-. +-- <br /> / Cr {❑{ �1C �?vr..-. #a � <br /> 3 4 i 0 n 'i.+ d 0 C-11M Crk- 50;1 <br /> NOTE: aFFSiTE SORINGS REQUIRt ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this applicatlan and thatthe warkwill be dans in accordance with San Joaquin County Drdinanees, State Laws, and Ru <br /> sod Regulations of tMe San Joaquin County- Homeowner or licensed agent's signature c"fles the!allowing; '•r cerlffy ehatln the perlormaneo ofthe wo <br /> farwrlich this permit is Issued,l slra►J oat smPloyprrsons subject to WORXERS'COMPENSATION Laws of California.- Contractors hiring or sub- <br /> =Irracting signature certifies the following:7 ceRlfy that In the perfarmarne of the work for which this permit is issued• l shaft emplay persons subject to <br /> WORKERS'COMPENSil7tID1V Laws or California,' <br /> T PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x title *CVLr � O <br /> ata <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> 13EPARTMENT USE ONLY <br /> Application Accepted 13y Date Issued <br /> —5410 L Area <br /> Grout Inspactian By Date._ Final inspection By Dare <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOtJNTINGONLY., pyp� FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#fCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBED INVOICI <br /> Gi.61 <br /> � .. _ �. '`4.__..fir.. URL - <br /> UN:T IV-6/23/99 Isign bkpg1Mr <br /> � � �� � � ( k <br />