Laserfiche WebLink
2-10-2000 11 :24AM FROM P. 1 <br /> WELL PERMIT APPLICATION FORM , T IV <br /> A <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'c� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <, aj <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 /> Assessor's C n J,Fe <br /> WELL Location <br /> ; ��✓Lti r� Reil. Cross Street i�,v- ( ��r City 11-uL Zip C 11 Parcel# <br /> PROPERTYOwner,}�Ik IZ,Ii Address k s ��b��Z City Zip Phone# <br /> Tk,g i1v eCSS <br /> C-57 Contractor. :lhc J Fitir- /�I- Address 2Z11 �����ti / City Lic# 5V10dcPhone#CSio)3,1? <br /> R,lci C� Lnc. e6 `U <br /> Consultant/Sub Contractor 61 i- ' J CIyc� "Cr b42-Address, u' i i %- City.�i<�`li.�( L;c# Phone#CS10 7-�- k'c> \ <br /> GIS Coordinates:X Y Township_ Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(choose typeBlow) <br /> Q SOIL BORING# Z Itic o4--�6OVER-BORE Cul"'- I� <br /> 0 WELL# �QI weVS-� PRESSURE GROUT <br /> 1UIW-� v '1 r S w Zi <br /> "Other: <br /> -2 "1 <br /> COMMENTS: % <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C <br /> 0 MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS?0 YES p NO WELL CASING DIA <br /> Q EXTRACTION j]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC 0 OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOvE PIPE <br /> 0 <br /> OTHER:_O OTHER 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 Rut s <br /> and Regulations of the San Joaquin County, Homeowner or licensed agent's signature certifies tha following: r1 Ce lify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSA77ON 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 Cafffomie." <br /> CALL'THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVI�►NCE-FO R ALL REQUIRED INSPECTIONS. <br /> — - Title/Company G �-��1 ori i! 'l u'C�✓ � C�2Z�� <br /> Signed.. <br /> Print Name �1�t� Z� Date „• - -_ - ^"t<� <br /> SEE....StfE:MAR='!N �UI�#; ��)t�;�:�l�l'�i' 'P. .`_..`. 'DA"T`EE� rn::� °�;i•:. ...,.- <br /> DEPAR'T`MENT USE ONLY <br /> Application Accepted By <e_ Date Issued I r Area <br /> 2 Fina[Inspection By Date �{ 3 <br /> Grout Inspection By L r Lam, Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> PACCOUNTING&ONLY' AtD# FA <br /> CODES INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT! REQUEST# INVOICE <br /> 3� c z I,al� t I r/ oC) 13 ) <br />