Laserfiche WebLink
06/27/2062 12 05 2094663433 FIFTH FLOOR PAGE 02 <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) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applo-cahon 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 Serwees Environmental Health Division <br /> l 0 V N T Y P!,it tt i ti F G!t 1k46E Assessors <br /> WELL Location Q V E E Cross Street E•irrEti111 AVpty ST0CkT04 zip9S1o2 Parcel# <br /> PROPERTY Owner EAACILITIF_; MCrMT OEPI _Address"111 L.5r,0115 AVE CItyST4G*T0_N Zip9S20; Phonett(ug)46?-33Si <br /> C 57ContractorMrlGHFlL DA LV1NFr Address.IOGJ8 HILA114 WAY City O aV !ZIp9spa 1.106R . <br /> 116 IT Phone#(910631-3583ConsuilantlSubContractor R&MRCrF F-MV. Address PoOm $OX 16k9 Giy�VM RI��tA LIc#S$,5b Phone# (gob)3S4-31So <br /> GiS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 111 NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH MWD-AUGER OTHER-) Q DESTRUCTION(choose type below) <br /> 6 SOIL BORING 9 U OVER BORE <br /> a WELL# MIN-I MW-2- Q PRESSURE GROUT <br /> Other <br /> COMMENTS TWO DN-SITE GR0%JNDWATFR MOH130{ 114x- WrLLS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA OF BOREHOLE 9-IN MULTIPLE CASINGS?0 YES 11 NO WELL CASING DIA 1'1 N <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCK 40 TYPE OF CASING ()STEEL I PVC 0 OTHER <br /> APOR Q MUD ROTARY DEPTH OF GROUT SEAL 116- FT, TREMIE TYPE TO BE USED E AUGERS OHOSE <br /> Q AIR SPARGE fl PUSH POINT GROUT SEAL PUMPED Q Yes N No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING p HAND AUGFR APPROX BORING DEPTH 3 S 1=r- __g BOLTED TRAFFIC BOX or d STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? NO (if YES list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify hat I have prepared this application and that the work will be done in g oc*,dance with San Joaquan County Ordinances,State taws and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agents signature cenifies the following '7 eerbfy that in the perforrnance of the work <br /> for which!tits permit is issued,1 shall not employ persons subjeei to WORKMAN'S COMPENSA770N Laws of Californrs" Contractors hiring or sub- <br /> contracting signature certifies the following 'I certify thol in the performance of the work for which this permit is issued, l shall employ persons subject to <br /> WORKMAN S COMPENSAVON Laws of Callfomla" <br /> E PPLICANT GAL HRS IN ADVANCE FOR ALL REQUIRED INSS <br /> Signed M Title J DalePECTlO 2 0 Z_ <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED 1116101 <br /> DEPARTMENT USE ONLY <br /> AppliDate Issued M, Area...... <br /> Grout inspection <br /> Accepted By Date Final Inspection By Date_ <br /> G+oui Inspection By <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS <br /> r=AC# <br /> COUNTING ONLY AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKpICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 0-C 6S R# 0 <br /> UNIT TV- 6/1/99/sign bkpg/MI <br />