Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ' r . <br /> nil <br /> 304 E. Weber, Third Floor, Stockton , CA . , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin Countyy Development Title, Chapter 9-117 .3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> Gra " + g {-, s- Assessor's <br /> WELLLocation 749 E . Charter Way Cross Street Grant St . City Stockton Zip 95206 Parcel# <br /> PROPERTY owner Darpetro , Inc . Address3450 E1 Camino CityCeres zi,95307 Phon437 - 0771 ' <br /> C-57Contractor Frontier DrillAidargss 9333W . McDonald R Stock 73504 <br /> t� . tt952 # ' Pho11e69 - 0211 <br /> Calif , <br /> Geophysical Group <br /> Consultant / Sub Contractor AddressP . 0 . Box578341 CityModestOLick, Phone# 527 - 1247 <br /> GIS Coordinates: X 95357 <br /> , Y Township Range Section <br /> WORK TO BE PERFORMED --- - -"- <br /> X[GJEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER*) 0 DESTRUCTION (choose type below) <br /> O SOIL BORING r 0 OVER-BORE <br /> O WELL # 1 M n n i t o r ' n g O PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XfXMONiTOFZING XR HOLLOW STEM DIA.. OF BOREHOLE 8 . 5 MULTIPLE CASINGS? 0 YES )a NO WELL CASING DIA: 2 r� <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: O STEELXM PVC n OTHERI <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 25 Ft e TREMIE TYPE TO BE USED: p AUGERS OHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes Xjt(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 45 Ft . BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here) _ <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances , State Laws. and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "l certify that in the performance of tho work <br /> for which this permit is issued, i shall not employ persons subject to WORKERS' COMPENSATION Laws of California. " Contractor's hirnc or sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is issued, I shall empioy persons suDjeot ;n <br /> WORKERS ' COMPENSATION Laws of California. " <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> Signedx Tale President Date 8 / 28 / 00 <br /> SE SITE MAP IN UNIT IV WORK PLAN DATED - <br /> .J DEPARTMENT USE ONLY <br /> Application Accepted By_ � �- Date IssuedGrout Inspection Inspection By, (:a' of L�q P�z —Date-19 c i <br /> Final hlspeon 9vv Date <br /> Destruction Inspection By _—"�—Date <br /> COMMENTS / CONDITIS: pb <br /> Ile <br /> ACCOUNTING ONLY: AIDd FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT/SERVECE REQUEST NUMBER INVOICE <br /> Sal — ajl3 GD <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLAKkTION <br /> UNIT TV - 6/23/99 /sign bkpg/MI <br />