Laserfiche WebLink
1-28-2000 8: 18AM FROM P. 3 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <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 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 /> Q` T" Assessor's <br /> WELL Location \•Ll0'C� �� Cross Street %VuST City t-aq zip`W6 Parcel- �.3 -1AD'`o0 <br /> PROPERTY Owner W Address 1oc�j�^I�1JJ.� ire gk✓d City L. A Zip W2 Phone#3 I 0 �g IVv <br /> C-57 Contractor Y�tolt+'. Address LN l 'L 1• k4 ST City)AA"_Zip ' LiC#ZoY Phone# 510 Z�ls O`lv(p <br /> 4 <br /> Consultant/Sub Contractora,*-ye v. ilK Address 3?Zfn I�w�S '� Z City t�LLic# Phone#520 ?S4 5LO-46 <br /> GIS Coordinates:X Y Township Rang= Section <br /> WORK TO BE PERFORMED <br /> �Nr'"^"'�" / ORIN (CPT,GEOPROBE HYDRCiPUNCH,HAND-AUGER,OTHER`) O DESTRUCTION(choose type below) <br /> � L ORING# F OVER-BORE <br /> 1NELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2%% MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH lQ I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: OTHER CONDUCTOR CASING PROPOSED? (if YES.list specifications here): <br /> COMMENTS ` I or I or ni 2' 60C WN!cj Soil O <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: "1 certify that in the performance of the work <br /> for which this permit is issued,1 shall not smploy persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the f wi g: 'I certify that in the performance of the work for which this perrnit r'S Issued.I shell employ persons subject to <br /> WORKERS'COMPENSATION California." <br /> ALL HE U NSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company �rtd/Z�-cTuG' <br /> Print Name Date <br /> SEE Slit`!; <br /> ;IN E1NIT IV Wdkl PLAN DATED <br /> DEPARTMENT USE ONLY //- <br /> Application Accepted By Date Issued I w b O Area <br /> Grout Inspection By Date Final Inspection By UMME <br /> Destruction Inspection By Date <br /> D <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK- REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br />