Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES flECE�WEC) <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 FEB 1 8 2003 <br />(209) 468-3450 <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM�T�%R1�IF <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i o Iia th <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />�AAssessor's <br />WELL Location 7l/l -%% __� "e --94E mross Street � irr � City � Zip �� Parcel# <br />PROPERTY Owner ` - _Address L�C,Jf/JC%`/ City Zip �/�3TLPhone#?i- 2IJCI'73.Z <br />C-57 Contractor /Addressee,&bc ��l'v City_�Zip y,S�y�Lic#7'��O'/fPhone#0// - 77Lw <br />y/ <br />Consultant/ Sub Contractorax ILL Ate- - -l49-�,.� drLe,� .IyU *(S�Lci �%� <br />% City�57 <br />Lic# Phone# <br />c i�""� 5 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) _ DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL # PRESSURE GROUT <br />'Other: �/ ss <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS 1.0 <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: -- <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />T1 <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />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: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S 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 />WORKMAN'S COMPENSATION Laws of Califomia." <br />AP LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title <br />SEE SITE MAP N UNIT IV WORK PLAN. DATED ,..2-1o.-0/3 <br />D PARTMENT USE ONLY �J <br />Application Accepted By 0�z�. Date Issued ;�Xo�( Area <br />Grout Inspection By V W Date U Final Inspection By <br />Destruction Inspection By Date <br />11 <br />COMMENTS / CONDITIONS: 4V/^d � MU I P P l VAP V <br />FAC# <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#/ SH I RE IV DATE PER CER BER INVOICE <br />3570"1 s- s <br />C=57 INCENSED CONTRACTOR.. MUST SIGN,Lic 8& , S-",COMPETSATION DECLARATION <br />UNIT IV - 6/18/99 /sign bkpg/MI <br />