Laserfiche WebLink
7-24�-199y -S81FIM FROM _ <br /> ' <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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> Application is hereby made w San Joaquin County fora permit to construct and/qr 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 CountyAPublic Health 5erviees,EnvifAssessors onmental Health Division. <br /> 901V Ti�ItNfJe RQ Cross Street City :40AI Zip Zf(t) Parcel= <br /> WELL Location ?3p0 OOklC�4S3 GV <br /> 1 ,t• Address crf S j City ROSEVIL.LE Zip g&(—Phones ylG T83�2 d0 <br /> PROPERTY Owner vo%LuEY <br /> 1 Phon LO? tTZ' 71 <br /> L t,f����� ,1`O ,pl,t'` City`V�Ik65 ZipYS�li G <br /> C-57 Contractor--EQ cti F./JVti(61f1I�AfL�Adcres5399 SME41� I�GAI� p TiI'Liat Phone*(SSO O�d'�OIIO1 <br /> I` pa, ata `rs Ciry <br /> Consultant f Sub ContractorM /AI3dtrlkTE.3 L— Address _ <br /> GIS Coordinates:X <br /> Y.,Township 3N Range SQ E Section__ <br /> WORK TO BE PERFORMED <br /> '� <br /> DESTRUCTION(choose type below) <br /> XNEW WELL f BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER, OTHER-) Q OVER-BORE <br /> g SOIL BORING# XPRESSURE GROUT <br /> Q WELL s <br /> •Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> x MULTIPLE CASINGS?0 YES $NO WELL CASING DIA; _ <br /> a MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL ;O PVC Q OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> Q AIR SPARGE ',PUSH POINT GROUT SEAL PUMPED: a Yes ,g,No (NOTE: LTEUM IC BOF D FREE-FALL E PTE P PE H IS O,) <br /> $.SOILBORING OHANDAUGER APPROX.BORING DEPTH .330t BOD <br /> D OTHER; u 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 agents 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 subjecl to WORKERS'COMPENSATION Laws of Cafifomia." Contractors hiring or sub- <br /> contracting signature certifies the following: 'I certify that in Ma performance of the work for which Nis permit is issued. I shall employ,persons subject to <br /> WORKERS'COMPENSATION Laws of Celifomie." <br /> /�� /)tr�TfyH�E,(APPLIC//ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> Signed x <br /> NSPECTIONS_Signedx '^^�"'^r"'�' Title RI)SFCT 60u%tIT Date T�lt/99 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> '' II ,, '' � DEPARTMENT USE ONLY <br /> Date Issued Ol�C'1�1 Area 00 <br /> Application Accepted By Fcf�k/�" <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: O <br /> FAC& <br /> ACCOUNTINGONLY; AID* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECI�a CASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> '>S.o <br /> C-57 LICENSED CONTRACTOR.MUST SIGN LICENSE &WORKERS'COMPENSATION DECLARATION ` <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> r <br /> II <br /> t. _ a <br />