Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <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 />t_ Assessor's <br />HELL Location I ),fi `t ,Tpe _ Cross Street City Zip r Pi Parcet# <br />PROPERTY Owner Luc- cAw <br />Address bnt (1 F. I)k-IIUST City!�f a� tri ZipPhone# <br />7 Address <br />pp�� �/- <br />� S `"I L rt S7D ip�Lict 641,1, 'hone# 46 <br />57 ontractor <br />:onsultant / Sub Contractor s-�G- <br />Address 117-Al-itf City Lia Phone# �J <br />GIS Coordinates: X Y <br />Township Range Section <br />NORK TO BE PERFORMED <br />'-c— <br />NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />SOIL BORING # <br />I 0 OVER -BORE <br />0 WELL # <br />PRESSURE GROUT �\ <br />'Other: <br />O <br />'OMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />/ <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE -0" MULTIPLE CASINGS-, 0 YES "ZNO WELL CASING DIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS Ni 4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEA_ DC7 TREMIE TYPE TC BE USED: 0 AUGERS 0HCSE Z <br />AIR SPARGE PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes )(No (NOTE: MAXIMUM FREE -FALL DEPTH IS <br />'SOIL BORING 0 HAND AUGER <br />APPROX. BORING DEPTH 30 r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE n <br />OTHER: <br />CONDUCTOR CASING PROPOSED'>(if YES. list specifications here): J \. <br />COMMENTS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />iereby <br />certify that I have prepared this application and that the work will be oone in accordance wrtn San Joaquin County Oroinances. State Laws, and Rules <br />enc Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the `cllowing: "I certify that in the performance of the work <br />-or which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />7ontracting signature certifies the following: 'I certify that in the performance of the work for which :his permit is issued. I shall employ persons subject to <br />NORKMAN'S COMPENSATION Laws of California." <br />­71HE APP.LICA-NT UST 9ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />t/ r <br />Signed x i itle �r Date A� <br />SEE SITE MAP IN UNC4 IV WORK PLAN. DATED>�,� �� zu���g� <br />DEPARTMENT USE ONLY <br />.application Accepted By ti Date Issued 6 114 /9 9 Area <br />Grout Inspection By Date S Final Inspection By Date <br />�)PStrurtlon Insnection By Date <br />COMMENTS / CONDITIONS: <br />FAC# <br />ACCOUNTING ONLY: AID# <br />:1E CODES i FEE INFO I AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE I PERMIT/ EST NUMBER INVOICE <br />UNIT IV - 5/99 /MI <br />