Laserfiche WebLink
r .r <br /> WELL PERMIT APPLICATION-OrlhM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 344 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 andlor 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 Health Division. <br /> Assessor's <br /> WELL Location !6b S Qnc��riG .ver eR Cross Street W..It tk S City s�wal� o�n Zip q5-ZO2. arcet# i3 7 420_ I <br /> M c-Crar p e y oa <br /> W <br /> Vw1L� Address Cit Ziphone# <br /> PROPERTY Owner . ; <br /> C-57 Contractor Woedwe �1. Address?o36 City R.o —Zip 1116'71 Lit#Ila' -9 Phone# 0-1-3-14-klov <br /> i Rar+uTta 68i^I3" <br /> Consultant/Sub Contractor i7 .b er s Address31�1UGald(o r�. 17o City Car a�a Lac# 72t l Phone#916- <br /> Y Township <br /> GIS Coordinates:X Range Section <br /> WORK TO BE PERFORMED , <br /> B DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) [I OVER-BORE <br /> [I SOIL BORING# .I]PRESSURE GROUT <br /> J%UELL#SP-!( �$ -2 ,8 c •SP-3(p',$� <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ASING DIA: <br /> MONITORING 1KHOLLOW STEM DIA,OF BOREHOLE B MULTIPLE CASOF SINGS?a Q S ONOEEL WELL OTHER: 3�'{ <br /> [I EXTRACTION B AIR HAMMERIDRIVi N CASING THICKNESS • TYPE <br /> B.VAPOR B MUD ROTARY DEPTH OF GROUT SEAL 2� <br /> S9� S3�TREMIE TYPE TO BE USED: []AUGERS %JOSE <br /> FAIR SPARGE B PUSH POINT GROUT SEAL PUMPED: J Yes 0 No (NOTE: MAXIMUM FREE-FALL D1wPTH IS 30') <br /> B SOIL BORING B HAND AUGER APPROX.BORING DEPTH 3a1 ie if D .KBOLTED TRAFFIC BOX or []STOVEPIPE <br /> []OTHER:_B OTHER CONDUCTOR CASING PROPOSED? (if YES,,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> t have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> I[hereby certify that <br /> and Regulations the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify thatin 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 /> ce of the work for which this permit is issued, I shall employ persons subject to <br /> contracting signature certifies the following: '1 certify that in the performan <br /> WORKERS'COMPENS. TION Laws of Cafifomia." <br /> T AP , `(CANT MUST CALL aH:1NORKING HRS.IN ADVANCE„F//OR ALL REQUIRED INSPECTIONS; <br /> Title <br /> a�or c'Ieo� ryy sL Date 2 r3 a2 <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: pe-ae6or. ��� 2OaI <br /> DEPARTMENT USE ONLY D v y <br /> Date Issued` Area <br /> Application Accepted By Date <br /> Grout Inspection By Date 5 v Final Inspection By <br /> Destruction Inspection By Date r <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Zg>o '211:1 <br /> C=57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS'�COMPENSA'ITQN DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />