Laserfiche WebLink
F �~ WELLQERMIT APPLICATION F0,4M UNIT IV <br />} SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ° EC= i <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 AUG 2 1 2000 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> I,I <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 Joliquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> c L Assessor's <br /> W6Le' ocat C��"t i Cross Street City r'�"-'—' —TZip9sZD Parcel# <br /> (ate >� q] / <br /> ` PROPERTY Owner dress 1��a�T1� Cit ��Zip �hone# 77 �n�1�� <br /> IC-57 Contractor (�`� Yl/fiV�tyl �/1 #`Tic" P17one# 7 At-% <br /> li <br />" Consultant/Sub Contractor Address City Lic# Phone# <br /> ` GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED - , <br /> 0 NEW WELL/BORING CP , EOPRO HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> ING# 0 OVER-BORE <br /> 0 ELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'Jk<GERS CHOSE <br /> 0 AIR SPARGE WPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B'bIL BORING 0 AND AUGER. APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 00 <br /> HER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: rR2P.Mr _ � I � y1 Da <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,Slate 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,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." 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 California." -) <br /> THE APPLICANT MUST 48Wd <br /> CALL" ' RKIN'd HRS IN ADVANCE FOR AU2kEQUIRED INSPECTIONS.' <br /> it s._. _ <br /> Signed xa &14 Title <br /> SEE SITE MAP IN UNIT IV WORK PLAN DAT D: t/ai/n ` <br /> �j DEPARTMENT USE ONLY -- <br /> Application Accepted By 6�e,h Date Issued Area C> S3- <br /> Grout Inspection By Date // Final Inspection By Date <br /> Destruction Inspec' Date l.J/!s/a� -/t✓v 4 o,— ` <br /> COMMENTS I ONDITIONS: SV FS - _ <br /> ACCOUNTING ONLY: AID# } <br /> I. PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57,LICEIVSED CONTRACTOR MWST,SIGN LICENSE&WORKERS' COMPENSATION D_E_CLARATIO_N___ <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />, J <br />