Laserfiche WebLink
ORIGINA, <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 />Asses <br />ivision. <br />Assessor'sVn �D��2� <br />WELL Location 2.10-3 cn -NiQY C.1 Ups j3t-V n Cross Street r PAN�LYr4t City STCX l`TU��! Zip • r;Zu4 Parcel# (i <br />PROPERTY Owner ��� SP'f�INti�_Address 3535 wzr,niaAM c-re"E City STOCkTON Zip ' c` Phone#C�og)c15L-5225 <br />RAN c -"o <br />C-57 Contractor CA`)C/-NDE DS:TLLZNC Address )6' 2. (iMEC CLF -CLE City co2no•fA Zip,1­3"i&A1Lic# 1175 is Phone#5 X11y) >�;- t 169 <br />,NpIANCEfI GEC - <br />Consultant/ Sub Contractor TAJ. T-r*Address 3 l S NAw ►a1. City 5-ock-TcLic# Phone# (zc�i)yt,�-IcGC> <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />$,WELL# i-1 NrAD V\W -\5C <br />'Other: <br />Range Secti <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />COMMENTS: RCFEi2ENC_F!�i �AcN� Ll 'vJo'r�� 4 Ll�ti DHT��I 1rj TANQIARZ ZvC3-(. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING tHOLLOW STEM DIA. OF BOREHOLE `,S MULTIPLE CASINGS?AYES 0 NO WELL CASING DIA: 2 " <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS scHeoiLe 4o TYPE OF CASING: 0 STEEL BCPVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ,g AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: fYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH SO 'p.w S-, go � -g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER -_0 OTHER CONDUCTOR CASING PROPOSED?�4A 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 Reoulations 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, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub - <br />.contracting signature certifies the following: "l certify that in the performance of the wort: for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company STAFF `tiZENTLST/ A(1vNNCED G ECEh1VSSZoNhE1vT-/�L <br />61 <br />Print Name 't3ECKY J Er Date 21 "a ?- <br />SEE <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued / <br />Grout Inspection By <br />Date ii Final Inspection ByWA to / o <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEP INVOICE <br />Z�2-�2-- <br />CW4 <br />24 13 Q S R # OB So <br />8/2000 <br />