Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES O R <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 Z`5 <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 />C",,,,+Y t Clv6 61400 _ <br />. S ` <br />Assess <br />or'sWELL Location C� N O Cross Street fnAK1yn !9A—City Parcel# <br />PROPERTY OwnerFC <br />Addres5,?C21ZLity 5 l ?c K 7 -r i Zip �)5 Z��{Phone# d:7--,-b�� <br />c <br />C-57 Contractor5-1 In(, L l lc } D,7 9 Address 523 �.; }2c,t-, ,. Jo 5t City tr—e Z;p�i 5% t�ZL;c#,S� t �IPhone# �I Jb ay` Z 7 <br />Consultant/Sub Contractor�j , . Address 7oC S L. Lv,15�%-) �rCity 5 tnct(T-r-�Lic# t,S C1 Phone#k-� �% �n <br />GIS Coordinates: X Y Township / Nil Range F Section 2-9 <br />WORK TO BE PERFORMED <br />)(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0,SOIL BORING # <br />WELL <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />," MONITORING <br />HOLLOW STEM <br />O -EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMMENT <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT (� <br />W <br />DIA. OF BOREHOLESS� MULTIPLE CASINGS? 0 YESNO WELL CASING DIA:L�c- l� <br />CASING THICKNESS S� yc1�V�C TYPE OF CASING: 0 ST411L.,JJ�PVC 0 OTHER: <br />DEPTH OF GROUT SEAL Z F�, C I- TREMIE TYPE TO BE USED: 0 AUGERS _�SE (� <br />GROUT SEAL PUMPED: 0 Yes 1'No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') C <br />APPROX. BORING DEPTH ZS Jf C i `9 BOLTED TRAFFIC 60X or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? jLZ !4 ( if YES, list specifications here): <br />i <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 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 />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />Title_/, /���C'f` �C=�oSI,�T Date6l1-.r / `l. C. = �i <br />V <br />SEE SITE MAP UNIT IV WORK PLAN DATED: � ��,� 1 ��;�►�; <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />Ium <br />Ilk i Ox MUS 1 SIGN LICENSE &WORKERS' ( PFNSATION—DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />ACCOUNTING ONLY: <br />AID# <br />FA <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P IT <br />INVOICE <br />35oI <br />f` Z7 T T,( T7XTCrT% <br />M\A1 <br />'� <br />p <br />7SERV�ICE;REQUE <br />�2x� o I r <br />Ilk i Ox MUS 1 SIGN LICENSE &WORKERS' ( PFNSATION—DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />