Laserfiche WebLink
' <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 /> <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 <br />WELL Location 2462- PA./FIL Cross Street CAS ritr: City ST6CIL.FLA/ zip9S263 Parcel# <br />cfp 0,4V/) AreA.JATE42.... <br />Zip 95-20 Phone# QV/Pfks"-- 34'V City ST6444-704( <br />Phone# (64'(3i 727C, <br />(zcq) <br />Consultant / Sub Contractor/1E0404D err& Et44/20 • AddressiittSJ. wiLsckt umy citySraa.iirki Lic#6..86221 Phone# .7(L7 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />Tr,,IEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 EPIL BORING # <br />VWELL # <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br />COMMENTS: <br />PROPERTY Owner.laoTa SLOTT Address Po FO)<, 4316 <br />PAN cao <br />C-57 Contractor WEST UAZ, MAT Address 32 3? 1l1Zaa4f--6 r.3 City eter.)oll4 Zip g712 Lic#63,079 <br />LL THE <br />Signed x <br />Print Name <br />Date <br />Destruction Inspection By/ <br />COMMENTS / CONDITIONS: <br />TYPE OF WELL INSTALLATION TYPE <br />00NITORING tyHOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: U OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE PI/ MULTIPLE CASINGS? 0 YES §-t(ro WELL CASING DIA <br />CASING THICKNESSSCO qv TYPE OF CASING: 0 STEEL 45VC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [tAUGERS OHOSE <br />GROUT SEAL PUMPED: cf-1-'es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 90 LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Nit ( if YES, list specifications here): <br />Z ft <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 Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ 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 Law,s of California." <br />IT I INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/CompanyST4FF CTEoLoc,(57— A7-v:4-rafe LIT& falidOirtliRCAi <br />Date CS — 03-60 <br />SEE SITE MAP IN UNIT ,IV WORK PLAN DATED: 16 Migy ZODO <br />i I <br />DEPARTMENT USE ONLY <br />C . Application Accepted By 7, C r 6 , <br />Date <br />. ,Date Issued ,40(i 3- , toc, Area <br />Grout Inspection By ''f(' Final Inspection By <br />ate <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! F ji-V4CF EQUEST # INVOICE <br />q , ° (") Itt Di 5— Mjn <br />1/18/2000