Laserfiche WebLink
• • <br /> 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 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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,Environ ms oalsHealth Division. <br /> WELLLocation 3004 bIo(I4 .4 W- Fy­&M64T 5T'Cross Street l/1aa Bdvavl City S('0((S1oti Zip q Y04 Parcel# <br /> PROPERTYOwner tic If 510(100 Address City Zip Phone# <br /> .th1 <br /> d d �^ $ Address t yCity 14 ^ Zip9h)4' Lic#` f0}�?Phone#�67^f006 <br /> C-57 Contractor Ryaxc+ o Nvivr4M 1'IOOS N.LU� 1 •ti �0. <br /> Consultant/Sub Contractor Address City Lilt Phone# <br /> GIS Coordinates:X.,y.,Township Range Section <br /> WORK TO BE PERFORMED <br /> Q•NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> &SOIL BORING# 16 F-7 0 OVER-BORE <br /> 0 WELL# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1 r MULTIPLE CASINGS?a YES ANO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS VIA TYPE OF CASING: 0 STEEL B PVC BOTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I,P' TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE [LPUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> '(SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 'SD a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER:_9 OTHER CONDUCTOR CASING PROPOSED? — (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 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 of the 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: "1 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 /> CALL THE UNI//T IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed 74"4 � Lc/��//'1eit,1/L/� Title/Company /'ICINa1a(+ol �Eo�N b'1✓b vI Wll Lj �d 11 SNC, <br /> Print Name K o u r 1n H e 15 1 k-h Date N - 5 -0 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> MiDate <br /> � DEPARTMENT USE ONLY r1 <br /> Application Accepted By Date Issued " 1" � v Area <br /> Grout Inspection By 7 inal InspectionBy Date <br /> Destruction Inspection y COMM ryryTS 44 CONDITIiQO,yS: j S AVL e- $ i7tR ./ICW 1 b2 b 41Q n ofJAJ P <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2 of $ao� gq .00 US6bL+ I M �MSR# 00 6 <br /> 1/18/2000 <br />