Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES1 /; 'L <br />(� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />BAR 15 2001 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ENVIRONMEI�I HE-ALH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location -�-"KJ r�. iY'Ay IrL S1. Cross Street C;)(-r�,P,i^,A City Sficc.Mwl Zipf! v,WZ..�arcel# <br />PROPERTY Owner H, ct iVA2GZ Address L' �/X �(°�D `� City . Zip< Phone# <br />C-57 Contractors C �� �" iLi Address ��(�✓ im 1(,u) ki CityS0C.K_jcl I Zip9�c=}Lic#� Lbhone# v`f <br />�- w <br />Consultant / Sub Contractor I?jLti LL l'� �'l "t%�? _ ss%Z%�( zi PnQ0 (2 r— ��ty [2 Lic# Phone# <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT <br />'Other: <br />COMMENTS: <br />Y <br />Township <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />[] SOIL BORING # <br />I] WELL # tAA& l� <br />TYPE OF WELL <br />INSTALLATION TYPE <br />18'MONNITORING041101-LOW <br />STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMMENTS <br />Range Section <br />) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS �I <br />DIA. OF BOREHOLE '" MULTIPLE CASINGS.? 0 NOLL CASING DIA: 0 <br />CASING THICKNESS TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />DEPTH OF GROUT SEAL /�L' TREMIE TYPE TO BE USED: 0 AUGERS WE <br />GROUT SEAL PUMPED: es [] No (NOTE:M9XIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH / L 5 6 OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSE D?__O_ ( if YES, list specifications here): <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: `7 certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons 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 />* CALL T IV SPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x Title/Company <br />Print Name F 20 1 t E L k '� l (e ' �� � L:. Date J Z1� <br />_2 <br />SITE FILE ADDRESS/WORK PLAN DATE: <br />Application Accepted E <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIO <br />Date <br />1 %i 14 ► // <br />Date Issued 3 ` L I ^y ! <br />.Final Inspection By <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE AMIT <br />INVOICE <br />x.5-0 <br />� <br />`� <br />3 D 5 <br />C-57 exp._ WC/waiver C-57 Letter of Authorization to sign permit Encroac mei— nit oc(s). 5/17/00 <br />