Laserfiche WebLink
FAC# <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#'/CASH PERMIT/SERVICE REQUEST NUMBER INVOICE RECEIVED BY <br />5 <br />UNIT IV - 5199 /MI <br />WELL PERMIT APPLICATION FORM UNIT IV <br />RED-Livr- AI . 1.'",-,1 - I.C1164 <br />'1 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />VIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />DEC 28 1999 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />iL,NViRONiVIEN( AL HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT / SERVICES <br />A.pplication is hereby made to San Joaquin County for a permit to consul.= 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 />I <br />C <br />VD <br />o....n Di-,,, civt6 P,ILe , i <br />Assessor's <br />WELL Location V65(0 Co,,,-,44 -,i C I\,a, 13 Cross Street miSS, R./lo City S-Toc it. 7 ,)r), Zip 95Q 0 1-i Parcel# <br />PROPERTY Owner pH I./ E L)1 Address Li 2-43 \-1V • .0 Se wellilZ 19x/eity /0/W7W , Zip 9 S'YA, Phone# '20 c1 -55 2---- 7 or)3 <br />-Saizsigt..14444--Sub Contractor /\••I ti-c_ke II Df-; I lir\o) Address 5'56e , nt,e City-Scictom9d-cLi 7 2-‘13 Phone# 11IC T -7 <br />CIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER') <br />0 SOIL BORING r: <br />WELL t W .' I I i m • NIA.1-- M <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />9 PRESSURE GROUT <br /> <br />-Other <br />COMMENTS: <br /> <br />o i( <br /> <br />0-57 Contractor r‘A\ ;i4.)(eL) En, Address uv45(1rN ity /o Pr-•‘Zip cigzr)SLi ba.C 22 7Phone# 2. 0c ) LNL '7/ no \Q <br />TYPE OF WELL CONSTRUCTION TYPE <br />ONITORING )HOLLOW STEM <br />9 =XTRACTION 3IR HAMMER/DRIVEN <br />9 VAPOR 9 MUD ROTARY <br />2 AIR SPARGE 9 PUSH POINT <br />9 SOIL BORING 9 HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 13 - itv_,14 MULTIPLE CASINGS? 0 YES <br />CASING THICKNESS' )40,1.1 tio TYPE OF CASING: 0 STEEL PVC 9 OTHER: <br />DEPTH OF GROUT SEAL (0 cc., 0 TREMIE TYPE TO BE USED. ....1k-AUGERS °HOSE <br />GROUT SEAL PUMPED: ci Yes •KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH "so - ,rLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED' if ES. list specifications here): <br />WELL CASING /.(t <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />. hereby certify that I have prepared this application and mat the work will be done in accordance with San Joaquin County °romances, State Laws, and Rules <br />and Regulations 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 WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />7.ontracting signature certifies the following: '1 certify that in the performance of the work for wnicn :his permit is issued. 1 snail employ persons subject to - <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVAN OR ALL REQUIRED INSPECTIONS. <br />r e u•-___--- Title 1403 c_ -1- Cro)05/.)) Date /2- --- 2... <br />N UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Date Issued Area 06eCi <br />Final Inspection By Date <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> <br />Date <br />?It --11.414146° /je/tC / V' <br /> <br />Signed x <br />SEE SITE MA <br />Application Accepted By <br />Grout Inspection By Date