Laserfiche WebLink
N <br /> WELL PERMIT APPLiCATIOFORM UNIT IV�.� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � s UJ• <br /> ENVIRONMENTAL HEALTH'DIVISION (PHS-EHD) ..� <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 OR I G A""`� <br /> � <br /> (209) 468-3449 6` <br /> NON-REFUN260LE PERMIT fAPIRES 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 <br /> �Title,Chapter 9.1'115.3 and the Standards of San�loaquin County Public Health Services,Environmental Health Division. <br /> WELL Location W r"llGw 6�}G��Cross Street ' City Zip!' 3 Parceq� <br /> PROPERTY Owner <br /> ,address Gf City v Zips&Phon 3 W& <br /> ?z7& <br /> C-57 Contractor dress Z �► CityZipiPtron ��o" <br /> r►sulta 1 Sub Contractor Address's, A&a_a&&&itv V kALich <br /> GIS Coordinates:X_ :Y Township Range, <br /> Section <br /> WORK TO BE pERFORMED <br /> WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> [j OIL BORING# a OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> •Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,g"1(AONITORING }HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES .01116WELL CASING DIA: Z I l <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS l TYPE OF CASING: U STEEL�PVC Q OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL )r _- TREMIE TYPE TO BE USED: 'AUGERS pHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes -ErNo (NOTE: XIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER. 0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: J" <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 of the work <br /> for which this permit is Issued,I shell not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the folio ing:11 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 CaNdmia." <br /> THE APPLICANT MUST CALL 48 WORKING HRS,,IN 1.ADVANCE FOR ALL REQUIRED.INSPECTIONS. <br /> SignedX Title T��l1�dPlst Date I �V <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued ZOO Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I0­1 31 2r, 30 # WZL5.& <br /> C-57.110ENSED.CONTRACTOR MUST SIGN LICENSE&WORKERS'COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />