Laserfiche WebLink
WEL&ERMIT 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 l <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 /> Ci T7 RiGf{7 aF. wa / wilyo� o-� C Assessor's <br /> WELL Location ueot N£ C-nnv2 F `^"IfOri Cross Street Mo0.KcT STC@y S Tpc.K'fpr�Zip 15ao5 Assess <br /> PROPERTY Owner. `t n Lvf)r' <br /> 14 Address-/ DI S."7/4 INt)Snrl City STnCICTnn Zip 5zr phone# <br /> 11 ` AlRr�9 0 Rq"r`H o SSY�75 <br /> C-57 Contractor �E.ST NanA i Address 3aa� Fid JttP rull� City_C —PuN C— ZipC57VR Lic# Phone# n- <br /> nc <br /> Consultant/Sub Contractor . �r Address 9 G O 5 7 <br /> /�/. k/IIS nCity S%o,Il Ton Lit# oZ2 Phone# zac7 Yle7 /Qob <br /> GIS Coordinates:X.,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL/BORING CPT GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# Q- p OVER-BORE <br /> 'Other: 0 WELL# p PRESSURE GROUT <br /> COMMENTS: CV-1 bam'co)5 will 6C A anc n h r 20 — 7,—/ <br /> Q ,( <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -- <br /> o MONITORING D HOLLOW STEM DIA.OF BOREHOLE Q ircke)MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA: N(4 <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS N/,fq (T�,YpP�E'OF CASING: a STEEL 0 PVC 0 OTHER: h� <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL./o-I A I r'CI'K TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH /n o Ff i"I- p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /p OTHER:_0 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: "t certify that in the performance of the work <br /> for which this permit is issued,I shall not employpersons 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 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Sioned x J(`�YL1G /IlM(Y/J�h Title r_o107 Date -- <br /> {3rian /U�Ilko� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> " DEPARTMENT USE ONLY 'I <br /> Application Accepted By�ijAw.,,�.ey�...!/1tG.•_ Date Issued T41O -ZLxN-D Area <br /> Grout Inspection By—--1 a n IL L1 )2 Date �� 0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 36flI I1355 0 3 <br /> C•57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />