Laserfiche WebLink
Applica <br />San Jo, <br />WELL <br />DROPI <br />-57 C <br />Coma <br />WELL PERMIT APPLICATION FVRM <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />1 �6 ti0�� �P 2D X <br />Weber, Th�Floor, <br />468-�akttan, CA., 9202 <br />. <br />UNIT IV <br />GIS Coordnsates: X Y Township Range Section <br />w0RX TO BE PERFORMED <br />Li NEW WELL i BORING ( CPT. GEOPROSE, HYDROPUNCH. HAND -AUGER. OTHER1 l3 DESTRUCTION (choose type below) <br />04SOIL BORING o o OVER -BORE <br />a WELL = p PRESSURE GROUT <br />*Other. <br />C3AMENTS: <br />-YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING p HOLLOW STEM DiA. OF 9OREmOLE f,,_&- MUL T1PLE CASINGS? Q YES p NO WELL CASING DIA: <br />a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC a OTHER: <br />3 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS DHOSE <br />3 AIR SPARGE A (PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />01S01L BORING HAND AUGER APPROX. BORING OEPTH a BOLTED TRAFFIC BOX or Q STO E <br />PIPE <br />0 OTHER CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! amft <br />hereby Certify that I nave prepared this appiication and that the worts will be done in accordance with San Joaquin Counry Ordinances, State Lays. res <br />and Regulations of the San Joaquin County. Homeowner or kensed agent's signature Certifies the toNowing: -1 Certify that irr the Performa=¢" 01rk <br />for which this perrnit is issued. I shoji not employ pons subject to WORKMAN'S COMPENSATION Laws of Cailfomia." Contractor's hiring <br />=ntractirg signature certifies the tohowing: 'f Certify that in the performance of we worts for wnicir this permit is issued. 1 snail empby persons sub"iW <br />;NORKA"IWS COMP.4N4Wr7QN Caws Of C&NWT 4.' <br />V^AP LI MUST ALL 48 HRS IN ADVANCE FOR ALL <br />REQUIRED INSPECTIONS. <br />�7 , <br />Signed x <br />Tale tSc..ff Date ~ =—— <br />;400 - <br />SEE SITE MAP IN UN IV WORK PLAN. DATED 12 <br />DEPARTMENT USE ONLY j <br />Date Issued <br />Application. Accepted Sy 1_ l 1 j b 4 ,Areas <br />Grout Inspection By Data [ 00 Final pec <br />By f Date_^� <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />' ACCOUNTING ONLY: AIDAt I <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECKSICASH I RECE1VE0 HY i DATE � PERMITlSERVICE REQUEST NUMBER INVOICE <br />3S-01 <br />U13YT IV - 5/49 /MI <br />1 0 a ! 110-�- <br />a1G3 <br />