Laserfiche WebLink
06/09/00 FRI 09:30 FAX 209 948 0621 C�002 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOACQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andior install the work described. This application is made in Compliance witn <br /> San Joaquin County Development Title,Chapter 9-1115.3 and tho Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> MV 0, Assessor's <br /> WELL Location?`/ Cf fGMr--aF�WA>lboross Street tt1-r£/ZO(d2/Fr-_City S �'I�rYnJ zip Parcell <br /> ru1zn i> <br /> PROPPRTY Owner P47— Address L 7F,. 4"Aff City S-rveI2T zip 145-2-0 phoneT 9 Hv- <br /> HEW DRILLING CCIIVAA�, INC. 9 i #604987 <br /> C-57 Contractor P.0.BOX CityPALO AItIp�,^�� Phonem <br /> 51182 CA t�dyy- 120, 285 <br /> Consultant Sub Contractor k��r� F'l�GD Address �'V7� t' -ft Gity ,+, -rgI ) Lic# Kane# 'lff-I <br /> GiS Coordinates:X Township Range Section <br /> WORK TO BE PERFORMED <br /> ANEW WdEL*l ORI (CPT,GEOPROBE, HYOROPUNCH,HAND-AUGER,OTHER`) QESTRUCTION(choose type balow <br /> 0SOlt.BORING#,- ilrro�G•M ._>f�j . �" OVER BORE <br /> a WELL# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE—LL MULTIPLE CASINGS?d YES d NO WELL CASING DIA: _ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL a PVC 0 OTHER: <br /> 0 VAPOR [(MUD ROTARY EPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS (]HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER APPROX,BORING DEPTH x o Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> p <br /> OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: Sx , E gg <br /> ScC CA(-- t=M.tLeAclt VPIe 4n tN C-tLC- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the worst 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: "I certify that in the performance of the work for which this permit;$issued, t shalt employ persons subject to <br /> WORKERS'COMPENSA TION Laws of California.•' <br /> CAI A2 THE-UNITiVASPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x TitSe1Company /- 7 <br /> Print Nam L,4U'f C-1 Date t o <br /> SEE SITE MAP IN UNIT IV.WQRK PLAN DATED: <br /> DEPARTMENT USE ONLY � <br /> Application Accepted By 1 �" '''� �"" Date issued (0- l6i" Area__ <br /> Grout inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS' #,,Lk Qk& PGRE YrWVT666k) <br /> >IkDD T1UtiJ 4tdP.aL e7y1�Q fitrt►J o1ftLoS fgd&� t %J <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> no ' <br /> 1/!8/200 <br /> WC I W- \, J� A <br /> ml I AL, <br />