Laserfiche WebLink
,i <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) 468-3449 <br /> j� 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 Health Division- <br /> r�"' �{ <br /> Assessor's <br /> WELL Location:34 J r Cross Street -� City:t`qe Zip Parcel# <br /> PROPERTY owne i [ tise.S Address p.0.C30?X T+sb� CityBG�ti �cZ/1 Zip f�!_ Phone S_t 3Cls- <br /> C-57 Contract. T"_. r Z Sl � 41/Address ( r�� f7OCsJe� •r City A/ Ix Zi �.ri3 Lic# IOC4 Phone# ?� tl'3—S� <br /> Consultant I Sub ContractopfiR.Mb r—i' 1/i lrr"a 64ddress Z�6 City t+ _Lic# Phoneifl_ 4 <br /> :i <br /> GIS Coordinates:X ',Y Township Range Section <br /> WORK TO BE PERFORMED <br /> (�NEW WELL I BORING(CRT,GEOPRO13E,HYDROPU CH,HANDUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> .SOIL BORING# OVER-BORE <br /> II WELL# PRESSURE GROUT <br /> 'Other: <br /> i <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA,OF BOREHOLEH MULTIPLE CASINGS?p YES Q NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIORIVEN CASING THICKNESS IV TYPE OF CASING: {]STEEL a PVC OTHER <br /> a VAPOR d MUD ROTARY DEPTH OF GROUT SEAL 10a, TREMIE TYPE TO BE USED: a AUGERS OHOSE <br /> p AIR SPARGE IWUSH POINT GROUT SEAL PUMPED:;KYes p No JNOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> JI-CPOIL BORING [I HAND AUGER APPROX.BORING DEPTHI oG?�_ -__ ,-_-1]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 0 OTHER: n OTHER CONDUCTOR CASING PROPOSED?_ No (if YES,list specifications here): <br /> COMMENTS: <br /> u S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I <br /> 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.J Homeowner or licensed agent's signature certifies the following: "I certify,thatIn the performance of the work <br /> for which this permit is issued,I shall naf 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 shalt employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cafifomia." <br /> :CAL TN6.10. IV INSPECTOR '48'WORKING.HRS IN ADVANCE FOR ALL`REQUIRE�1NSPECTIaN5. I <br /> Signed 7 .rw.�r �'F� Title/Company s r�t Rlricl+-�IUiT�it+r / <br /> ii <br /> Print NameDate <br /> !i _�" �4�'7Tti'1N�^n► 3 Of 1 <br /> IKA <br /> DEPARTMENT USE ONLY L r <br /> Application Accepted By Date Issued71 Br Area Lofp <br /> Grout Inspection By Date/ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> 1i <br /> ACCOUNTING ONLY: AID# n <br /> i - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Yi 17 <br /> 1/18/2000 <br />