Laserfiche WebLink
WELPERMIT APPLICATION ORM 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 /> 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 9-11.15.3 and the Standards of-$an Joaquin County Public Health Services, Environmental Health Division. <br /> .r Assessor's <br /> WELL Location Cross Street City Zip Parcel# <br /> 0 <br /> PROPERTY Owner Address City Zip Phone# <br /> �i <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant I Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> i <br /> WORK TO BE PERFORMED <br /> { <br /> 0 NEW WELL I BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER'). 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# D PRESSURE GROUT <br /> ''Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> '0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? Q YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D.PVC ' 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT-SEAL TREMIE TYPE TO BE USED: . 0 AUGERS OHOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:. 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:-O OTHER CONDUCTOR CASING PROPOSED? (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 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 is issued, l shall employ persons subject to <br /> 'WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICANT MUST CALL 48,WORKI140 HRS IN ADVANCE..FOR ALL REQUIRED,INSPECT,IONS. <br /> Signed x Title Date <br /> SEE' SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date;Issued Area <br /> Grout Inspection By Date Final Inspection By. Date <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: Al <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST.,STGN LICENSE &WQRKERS' COMPENSATION DECLARA'T'ION <br /> UNIT IV'6/23/99/sign bkpg/MI <br />