Laserfiche WebLink
WELL PERMIT APPLICATION FORM , ,�fUNIT IV <br /> f <br /> Qi tUG 1" 15 SAN JOAQUINI COUNTY PUBLIC HEALTHg;)E %V�ICFS <br /> ENVIRONMENTAL HEALTH DIVISION ��� != !5 <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Aoplrcat,on rS hereby made to San Joaquin County for a por"ut to construct andlor install vii-work described This appficat70n is made to compliance wltrt <br /> San Jo3QUrn County Development Ttle Chapter 9-1115 3 and the Standards of San Joagwn County Public Heafth Services, E*wuonmental Health Divfsron. <br /> Assessors <br /> WELL Location s ►G-�o� �t)�� Crass Street B?LV v t`"(el City �-Od► Z;P �JZ� Parce}A 9--OSO - 3� <br /> S <br /> PROPERTY Owner Stti�'.ti1+PerwlllrK�P.r , Address 849 Wo 1kl? Cdy SWyAMM76 Z,p.��Pru�nea C2as 30-2190 <br /> C 57 Comractor IIV adress�O � � ` City �KLL Zip 3_L'C1( 16 Phenes (935)313-Sw <br /> Consultant 1Sub Con tractor L>�.Vyt10AFanvfrM,p,�Address <br /> GIS Coordinates X Y Township Range 'on,_ <br /> WORK TO BE PERFORMED <br /> EW WELL I BORINGCP OPROSE HYDROPUNCH HAND-AUGER,OTHER-) 1]DESTRUCTION(choose type below) <br /> OtL BORING to a OVER 80RE <br /> 0 WELL ft a PRESSURE GROUT <br /> 'Other <br /> CCfAMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 19NITORING a HOLLOW STEM DIA OF 80REHOLE '2 � - - MULTIPLE CASINGS?O YES Q NO WELL CASING Ow <br /> 01TRACTION p AIR HAMMEPJDRIVEN CASING THICKNESS lr!A TYPE OF CASING Q STEEL U PUC (IOTHER <br /> 0 VAPOR [;MUD ROTARY DEPTH OF GROUT SEAL LTREMA=TYPE TO BE USED 13AUGERS 13HOSE <br /> a AIR SPARGE 1kl�USH POINT GROAT SEAL PUMPED 0 Yes 13NO (NOTE. MAXIMUM FREE-FALL DEPTH IS 301) <br /> `,$SOIL BORING IJ HAND AUGER APPROX. 80RING DEPTH 59�r b BOLTED TRAFFIC SOX or p STOVE PIPE <br /> 3 OTHER CONDUCTOR CASING PROPOSED?_ 3O (if YES.I,SC speClfieaWns here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby cenify that I have preoared this app teat+on and that the work wdl be done In accordance with San Joaqulr+County Ord'nances State Laws and Rules <br /> and Regulations of the San Joaquin County homeowner or t+censed agents signature certAms the fouowmg It certify tnar,n the perfuo,marrce of the work <br /> for which this permit is rssuod:!shall not employ persons subjecr to WORKMAN'S COMPENSATION taws of Cal.fame.' Contractor's hmng or sub- <br /> contracting signature certifies The following -1 certify fhot in the per/ormanm of Ilse wprk for wnpch this ptrrmfl is issped l shall empfoypersonS subject to <br /> WORKMAN S C0MPEN5A7'10n1 taws of California` <br /> THE APPLICAINT MUST CALL.49 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> S19ned x <br /> -- rine Date — 31 - 01 <br /> Ili U <br /> SEE SITE MAP IR UNIT IV WORK PLAN DATED -1- 3 -00 <br /> EPARTMENT USE ONLY Q <br /> AppGralron Accepted By4 ' ' Date Issued • �� ea.�---------- <br /> 9y D Final inspection lay Oate <br /> Grout Inspection <br /> Oe5tructlen Inspection By Date <br /> COMMENTS 1 CONDITIONS r- /'- <br /> Lek (-) r O �� f <br /> FAC <br /> ACCOUNTING ONLY 7AIDt 71 <br /> PE CODES FEI`INFO AMOUNT REMITTED CHECKNJCASH REC VED BY OA E PffRMITISERVECE REQUEST NUMBER INVOICE <br /> 3 z8 <br />