Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 L <br /> (209) 466-3449 <br /> Lf <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/qf 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 /> Assessor's �l <br /> WELL Location 2 1 b3 CO u.ihi. c1�1 o� f4 k m Cross Street �1,.Irl.A City�4.c,Hrr Zip Parcel; <br /> PROPERTY Owner f "r TY. 1'Ct64.-c�tS Ce, Address nr)•G&A syby CitySLM l2&rw.Th Zip!N Phone#757-8'(Z-4645� <br /> C-57 Contractor `JAW all &n Icialf/vn ddress_`15-f,S , ->•IjkL�CNY6 r +, Zip !(C. Lic; zl Phone; 960-I'Z Z 37 q <br /> C;,de <br /> Consultant/Sub Contractor—I erre.. VL`a Address 011-1r rz,,... „err.. City /,.,v.;rc( Lic# Phone*. -73ZZ <br /> GIS Coordinates:X Y ,Township Range Section- <br /> WORK TO BE PERFORMED <br /> W EW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING; 0 OVER-BORE <br /> *Other: ELL; Wt- j-/ � 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1(� MULTIPLE CASINGS?13 YES g'NO W LL CASING DIA: <br /> 0--//EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Z�TYPE OF CASING: 0 STEEL 0 OTHER'. <br /> OR 0 MUD ROTARY DEPTH OF GROUT SEAL 9 TREMIE TYPE TO BE USED: GAUGERS DHOSE <br /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: eyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH ZD ' /-9d r 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 8 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED <br /> ( d 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: "I certify that in the performance ofthe work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: Y 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 California." <br /> THE APPLI ANT MUST CALL 48 HRS INADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed: IG��J/`-� Title ! ro ">; w,,-r . Date I i �S (r$ <br /> �--J <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued l Z^ Z�^r ! Area D� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS:10 909IM3M <br /> f <br /> ACCOUNTING ONLY: AID; FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK;/CASH RECEIVED BY DATE PERMIT/S RVICE REQUEST NUMBER INVOICE <br /> C67 LIGE SEIG ON'�I ACTOtt x Siec�t LTGENSE 3RK RS':C �v-! . # IQI�T p9GLetIt�4Ti�J T <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> Z d HoaA Hd£Z' 1 6661—ZO—L <br />