Laserfiche WebLink
WEL•PERMIT APPLICATION •RM UNIT Iv <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ORIGINAL <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,Environmental <br /> Health Division. <br /> WELL Location 21ci S R LLe fty-f`utAV AVL- Cross Street t c o City \V 0. zip Parcel# <br /> PROPERTY Owner <br /> Ytir_.I{� (` 2 W. Gym-e. VLA City 2V-0L _ ZlpI*Phone# <br /> n � C S Address (f K _ Z <br /> 1 F yJ 5 , 1R.�. city5�,,1 �p S21�Lic#�$O� Phone# `F�-7—(a0(o <br /> C-57 ContractorAnal^.,ror� Cc+�'`C'�:'"V"Na"AddressL6�.- --+yt <br /> Consultant/Sub Contractor_SVAWe-e- Address SmA&.11! City_' p,g Lic#_-'y,t�. Phone# ` QLIA <br /> GIS Coordinates:X <br /> y.,Township 1S Range RC t Section <br /> WORK TO BE PERFORMED <br /> '[NEW WELL/BORING(CPT, GEOPROBE, HYDROPUN,�yH,HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> 0 SOIL BORING# / 7 0 OVER-BORE <br /> D PRESSURE GROUT <br /> D WELL# <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> S•r MULTIPLE CASINGS? YES ONO WELL CASING DIA: PA <br /> 0 MONITORING D HOLLOW STEM DIA. OF BOREHOLE I� D <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: D STEEL 0 PVC BOTHER: N� <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 20! TREMIE TYPE TO BE USED: D AUGERS DHOSE <br /> 0 AIR SPARGE gPUSH POINT GROUT SEAL PUMPED: D Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> „SOIL BORING D HAND AUGER APPROX.BORING DEPTH ZD r D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 0 OTHER: D OTHER CONDUCTOR CASING PROPOSED? N.A (if YES,list specifications here): <br /> COMMENTS: <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 S 11 an 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: "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 /> CALL THE UNIT IV INSPECT R 48 WORKING HRS IN ADVANCE FOR <br /> ALL REQUIRED INSPECTIONS. <br /> Signed Title/Company �� /fY�f/A-ticc� <br /> 9 1 <br /> Print Name Date 0I -e— V, O <br /> ia\A '] � � .. <br /> SEE ;SIT MAP I ,",UNIT IV ;WORK PLAN DATED: <br /> DEPARTMENT USE ONLY 7 -y D <br /> Date Issued Z- L -0 Area <br /> Application Accepted By <br /> Date Final Inspection By Date <br /> Grout Inspection By L TED <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> UPECODES <br /> MFEEINFO <br /> LAMOUNTR;7EMITUTED <br /> CHECK# RECM BY DATE PERMIT I SEINVOICE <br /> � � 53 2• z• nI 002 3-S <br /> ijis '2000 <br />