Laserfiche WebLink
' - UNIT IV <br /> WELL PERMIT APPLICATION' FORM <br /> -: SAN'.JOAQIJ14 COUNTY PUBLIC HEALTH SERVICES �� � ,i � <br /> EN <br /> V-IR6NMENTAL HEALTH DIVISION (PHS-EHD) <br /> 0.0 BIL -3p4tfyr, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 , <br /> i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> )lication 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 /> i'Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ <br /> a sormental <br /> Health Division. <br /> 5S aQ Cit �i{ Zip Ql5 5 Parcel# <br /> LL Location of!✓J�`!S �� Cross Street Y <br /> I 6 t o 0(7 / <br /> 9 �- Phone <br /> OPERTY Owner .1 VOA cre►'-x Address a I� �dG�"Ie� SL(Lt City`lto +� �'C t Zip <br /> }r Address ` fv+ �.t.iiSrr; �� City t - ? ZipLic# Phone �G � <br /> I iT Contractor„ [ i <br /> �7L Address i;q__ 1. (,.,�SW� �a CitY. Lic# 4 i� .L Phone o`�� '/v�' <br /> nsultant I Sub Contractor j <br /> i Township Range Section <br /> Coordinates:X Y <br /> i )RK TO BE PERFORMED <br /> D DESTRUCTION (choose type below) <br /> SEW WELL 1 BORING(CPT,GEOPROBE, HYDROPUNCH HAND-AUGER,OTHER') 0 OVER-BORE <br /> {,SOIL BORING# i [] PRESSURE GROUT <br /> 0 WELL# <br /> i <br /> ther: <br /> I <br /> i <br /> )MMENITS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MULTIPLE CASINGS?©YES 10 WELL CASING DIA: /" <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE <br /> f <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OTHER: <br /> JAPOR D MUD ROTARY DEPTH OF GROUT SEAL_ n f _TREMIE TYPE TO BE USED: 0 AUGERS $HOSE <br /> MR SPARGE _XPUSH POINT GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 501E BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE P1PE <br /> OTHER: D OTHER CONDUCTOR CASING PROPOSED?„� (if YES, list specifications here): <br /> :t <br /> 'r <br /> .r <br /> j ]MMENTS: <br /> f NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> )ereby 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 /> id Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "!certify that in the performance of the work j <br /> r which this permit is issued, !shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or suo- <br /> mtracting 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 /> CORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE,FOR ALL REQUIRED INSPECTIONS. <br /> ig ned x lrT� r.[J � TitlelCompanTitle/Company, 3 'f l)eo)o <br /> Tint Name (" tJi)Gi Date DATE <br /> __ GaC.J <br /> SEE SITE'-MAP IN UNIT IV WQRK PLAN,, Q.. o <br /> DEPARTMENT USE ONLY <br /> E <br /> pplication Accepted By Date issued= �/ Area0-73 <br /> gout Inspection By _ _ Date Final Inspection By Date <br /> )estruction Inspection By •� Date -7l/.36'0 01 z <br /> :OMMENTS l CONDITIONS: -� <br /> 'i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY 77/ <br /> :PERMIT!SERVICE REQUEST# INVOICE <br /> C� %.. Ccs 33 Sy <br /> �i <br /> 1/18/2000 <br />