Laserfiche WebLink
WELL PERMIT APPLICATION FORM (( UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEF� �J`J�� <br /> Op� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JAN 15 2004 <br /> u 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location'��0 0 a &6 cross street 1—SRu ciitty�_ZIP IJ 33`] Parcel# GR-IuG-Z <br /> 1 pt hfl,_ _Zip ISIS (Phone# <br /> PROPERTY Owner o{ Ciz�ltl yl/G Address llI (UC'S"I A•Wf>'1N'1 City <br /> (rt Dr II' �i Address R5D l aty /li zip9 Lic#N I� Pnone#yZ53i3-5- <br /> C-57 Contractor LI � c 7 � ���i n� / / <br /> Consultant)Sub Contractor' `'^kVA i%t1V1/9Il{7'' J Addres;033� (�'✓A EM�� D11 City60UWA Uc# Phone#5 2-1kZ -�bZ <br /> SSo a/- ") L+'i �SZ <br /> -GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 7 0 OVER-BORE <br /> SOIL BORING# <br /> p PRESSURE GROUT <br /> 0 WELL# <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE�I`I/rN 1 MULTIPLE CASINGS?0 YES NO WELL CASING DIA <br /> E EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS(te`''ch TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPORv1UD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: 0 AUGERS ROSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: '$Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING O HAND AUGER APPROX.BORING DEPTH 1c;0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: U OTHER CONDUCTOR CASING PROPOSED? 611, (if YES,list specifications here): <br /> COMMENTS:, Z bolino ISL, G <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby ceruly that 1 have prepared this application and that thk wi <br /> 11 e work 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: "1 certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of Califomla." Contractor's hiring or sub- <br /> contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Caldornia , �,u `S= <br /> 19It~A L >xr fi t w, asl ra l r I #�T p /! _.IPI , R.- I- l _D�,._ <br /> Signed z �IW 7uY• ;` Title r is• 7L 7 Date /- <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: ja /So2 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B �iy�Q� K Date Issued =7�/ Area <br /> - <br /> Grout <br /> Grout Inspection By Date____________Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 8Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3sor Sagq °° 5355 UU3(o �Sly <br /> UNIT TV.6/23/99/sign bkpg/MI <br /> 1`402JA NVVS' 1 1 666 L-61a <br />