Laserfiche WebLink
DEPARTMENT USE ONLY <br />Date Issued <br />Date Final Inspection By ff":47717,T7,,,T7 <br />421-- 7-0 6 <br />WELL PERMIT APPLICATION FORM <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 Count Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. COv^ 0 , 0 ST4 R4 5 TAR SAAR Assessor's WELL Location <31:- iG 11 j— 1A) CroSst igtreet CAP/14-c.,L Avtfrot City LO 0 .1 *Zip 9ca ,fq Parcel# o5 Z - 1;u1417).5 <br />PROPERTY Owner 54 6 C) f Address (..)40/ LA P/-I AL /--/V City L Zip95?-1L Phone#(2Q cl) 3(07 955c <br />A <br />C-57 Contractor MST AZ- 041- Address SR 53 1/4 15erc./..0 City c_41).044v R zip95 7YaLic# Flone#0/9 <br />4k,dics ‹i,9 7 <br />Consultant/Sub Contractor G- , Address 10(15 ov, WI)Sun dity 5-/-ocgt),)Lic# W42 2 ?Phone$#0) Vie 7 /ool, <br />GIS Coordinates: X y <br />WORK TO BE PERFORMED <br />, Township .3 'Al' Range 5- Section )4 <br />ANEVV WELL / BORING ( <br />'Other: <br />COMMENTS: <br />EOPROBE, HYDROPUNCH, H.W4JGER, OTHER') <br />SOIL BORING # <br />AtyvELL # 111000---* N 5 <br />DESTRUCTION (choose type below) <br />0 OVER-BORE a PRESSURE GROUT <br />TYPE OF WELL <br />0 MONITORING <br />O EXTRACTION <br />0 VAPOR <br />o AIR SPARGE <br />'p011 BORING <br />0 OTHER: <br /> <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />MUD ROTARY <br />XPUSH POINT <br />0 HAND AUGER <br /> a OTHER <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE eD inc 4 MULTIPLE CASINGS? 0 YES a NO WELL CASING DIA: <br />CASING THICKNESS kJ/ 6. TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: I\JA- <br />DEPTH OF GROUT SEAL -&t-4 L 0ir74TREMIE TYPE TO BE USED: 0 AUGERS AiOSE <br />GROUT SEAL PUMPED: AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTC-I 15 0 P“.A-- 65(70 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? I ( if YES, list specifications here): <br /> <br />COMMENTS: 12)/(4ci i)çr c p-T , 41d,4 C /IA TV Zi) Lt O 1. a )6 4? (-) (Q <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS 0(R 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-contracting signature certifies the following: "/ 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 />JH APPLICANT MUST CALL 48 WORKING HRS IN A VANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title h V, T cc, Q5/Sate ril/o?Qp) <br />SEE SIT AP IN UNIT IV WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST INVOICE <br />35r3 i 4*8 A k411.-- 43/Y a:;&3' 2-(S R# COZZ352- <br />LICENSE &WORKERSCOMPfNATfONECLARATION <br />UNIT IV - 6/2 3 /99 /sign bkpg/MI