Laserfiche WebLink
WELL PERMIT . .PPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter " <br /> 9.11//15./'3 and the Standar/ds of San Joaquin County Public Health Services,Environmentalsots Health Division. <br /> Y/ I4 4X.Adel' mssStreet City S7C1GKZip '7,C 0bParceY# <br /> WELL Location .✓P 5 <br /> L A d / <br /> PROPERTY Owner ' <br /> Address s r20 � 'l.�ST city <br /> f�Z� `/266�none# 9Y9-7Sz Z/s5 <br /> n �o P o Iovo coy to -Zip S SY i�u Phone#�7s- -aS'3/ <br /> G57 Contractor'D 0 4io 4?.O^ Address �- L 1 <br /> // �' -r".-t-F .Sf'etlCi sOnorn.� Lic# Phoned-707-9,j5'YfSO <br /> Consultant! ub Contractor �C r"-O/i�. Jam' Address ZOO�P�u r3 H <br /> GIS Coordinates:X -Y <br /> Township Range Section <br /> WORK TO BE PERFORMEOED <br /> W W /BORING(CPT,GEOPR06E.HYDROPUNCH.HAND-AUGER,OTHER? p DESTRUCTION(choose type below) <br /> 0 OVER-BORE <br /> U SOIL BORING# p PRESSURE GROUT <br /> rp <br /> WELL# MLf-11 - <br /> -Other: <br /> C—MMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING O HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?)(YES ONO WELL CASING DIA: <br /> CKNESS <br /> 0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THI <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: n "2) <br /> l]VAPOR O MUD ROTARY DEPTH OF GROUT SEAL^'510 l TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0,AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH X,Qi-IIA/ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER X IQa�a ion,G /br`-J�CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> ` e r 4 <br /> COMMENTS._ [ r-r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> thereby certify that I have prepared this application and that Ne work wiU be done in accordance with San Joaquin County Ordinanres.State e s,and Rules <br /> work <br /> and Regulations of the San Joaquin County. Homeowner or licensed agenrs signature certifies the following: "l certify that in the performar{c@:a� a work <br /> for which this permit is issued,!shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractorks htnwg or sub- <br /> contracting signature certifies the following: "I certify that in the Performance of the work for which this permit is issued,f shall employ Personpvct to <br /> WORKMAN'S COMPENSATION Laws of Csfifomia.' <br /> ' n THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. 1-44 <br /> Dates Cr '-1 <br /> Signed z "''-•' (-< / - <br /> Title w <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued Ss� O Areae <br /> Application Accepted BY n ea-� Date a_I. L4.Z <br /> Grout Inspection By 11, •^r'r^ Oate `6 � o z Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI!lCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 2 - gR .o�i IslS s �3a 30� <br />