Laserfiche WebLink
J 2i JUU <br />CC -.7,l...".117NG ONLY: A104 I <br />nY), Area Date issued 1 5 0 1 <br />SITE: MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />;olicStion Accepted Bv <br />ct !nscecdon ay <br />Istr_c1icrt insaecton By <br />CNIMZ.NTS ! CON DMONS: <br />Date ThaI nscecdon By <br />Date 6 A I <br />;rec.. x ANA- <br />int Name <br />I iNvOICE <br />ricrcachrnert dot-. 7/1 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT' SYPIRES I YEAR FROM DATE ISSUED <br />:1=tion I ereoy mode to San _Iparjuin County for a permit to =Strut:: and/or instait the work desontdev.. This applicator is made :rt corm:Wan:a ...nit Sal :acLin County Development Title, Chapter S-1115.3 ana the Standards of San -caoun County P'.;:clic Health Services, Envifonmental Heeith Divn, <br />LL Location et—) • C <br /> <br />7-- ,O4 Assessor's S-4-Are_ei Cross StreetCe.-4%---k—ro-( City etk_CA / Ci.c,31 cCRarcelF E <br /> <br />RCPERTY Owner (-Z.& La_C(4, Nk_is E.?, Address 6D C.Th \ CAL. City —War. _Li zip q5-3-15,ophone# t3q,33s— 7 p---7 o[bra_i <br />-57 ntractor Co <br />NEW 'NELL / SCRING ( CPT, GECPR("SE. 'HYDRCPUNCH, HAND-AUGER, OTHER'', <br />G SC L .SCRING <br />a WELL P <br />C,MME.V7S: <br />CONSTRUCTION SPEciFicA.TioNs <br />A. OF ECREHCLE MULT!PLE CASINGS? G YES NC WELL CASING DiA: <br />CASING THICKNESS TYPE OP CASiNC_t: 0 STEEL. a PVC fl OTI-iEP,': <br />"L)EPTH CF GROUT SEAL TREMIE7YPE TO GE USED: [j AUGERS ()HOSE: <br />GROUT 3EAL C Yes flNc (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GP,DL;7 SP:,:CIPICATiCN <br />,APFPCX_ EORING DEPTH 0 BOLTED TRAEIPiC ECX or STOVE PIPE <br />CONDUCTOR CAS!NO PPcacs:L%-:;-7 f YES, !1st specatif:rs <br />ommE?•rrs: MU) -4 4- m&-3 CL( %2... 16(ictte // ISO 4‘..), 6e., <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS t•-,1:ki,i,c,.).pu.7:-eld <br />'leredy certify that have prepared this application and that the work will be done in accordance with San Joaquin <br />aunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />UJ IIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />1-ItleiComoanv Pre5i.6.1,3+ nip <br />Oats to 0/ <br />1_ : F:FTH FL.COF <br />=AGE a-, <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />'WELL INSTALLATION TYRE N (yCNITCRING_) a HCLLOVV STSM <br />E.XTRA.:7!CN 0 AR HAMMERJEIRNEN <br />7AFOR 0 MUD ROTARY <br /> <br />A:P SPARGE PLISH PC:NT <br /> <br />SC4L ECRiNG iHr-,NC AUGER. <br />D-7I- ER:Q 0T-ER <br />A—C-Lx-YVY\ Addrass 013‘‘)S- U-li kka-ifY911 CRY -444-- ZIO 9`-;;105 7..iW-/ 22M Ptio net,_2 7 /7 <br />snsultant : Sub Contractor 4 4Alle4ctre&ssi le) 7 6 • i 6 -4-Si7e E4City AO eV Liad ‘1-.S7-32V RhorleF.:X 97-330 '7..)-- <br />is Coordinates: X y , 7ownship Range Section <br />ORK. TO SE PERFORMED! <br />roi0 -I-- 3 <br />1 <br />‘OESTIPUCTICN :.,c.hocse type below) <br />0 OVER-BORE <br />ILPRESSURE GROUT <br />GP:7,LT SPEC:PK:A-710N <br />Pc% <br />* CALL THE <br />IE. CODES FEE INFO AMOUNT REMITrED t CHECK # REO'D BY ! DATE <br />350)-1 e,',c) et(po 35 la 3 I P7 (n1 aj <br />C-57 WC/WAIVER C-57 Letter cf Authorizaticrt o sign permit