Laserfiche WebLink
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 />Assessor l <br />WELL Location /57 0.1 6. 74":".":1; cross Street . City 6414-V Zip qC 330 Parcel# rtk-2/00 -15 <br />PROPERTY Owner fliZeitYnelie Address • /4' 741124OCity Celt-fop Zip q5.30 Phone#I 0 327 <br />C-57 ContractortiPqM I tale-II org,A)Address >TAJO 5. vlivir ti 13: , City MC: Zip 75ezilidt7zw 7 Phone#7161 —4-lo (,U <br />A DVANc :Zect) <br />Consultant/Sub Contractor Ge.c Erni heiWoatireetlfhirrhic *Address 400S-A)gilkil if CA) V6-1Y City 1GL Lic# Phone# 44/7 —(00(.0 <br />GIS Coordinates: X , Y , Township Range Section <br />'BZINAL <br />vIN WORK TO BE PERFORMED <br />tpiEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />9 SOIL BORIN9 <br />//tae 11]'WELL # <br />COMMENTS: <br />'Other: <br />D DESTRUCTION (choose type below) <br />o OVER-BORE <br />O PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />1246NITORING al-KOLLOW STEM <br />O EXTRACTION 0 AIR HAMMER/DRIVEN <br />9 VAPOR OMUD ROTARY <br />O AIR SPARGE 0 PUSH POINT <br />9 SOIL BORING 9 HAND AUGER <br />9 OTHER OTHER <br />7 it <br />DIA. OF BOREHOLE 8 11 MULTIPLE CASINGS? 0 YES t810 WELL CASING DIA: 4-- <br />CASING THICKNESS Sal 412 TYPE OF CASING: 9 STEEL 14jJen-6 a OTHER: <br />DEPTH OF GROUT SEAL 11) 6 TREMIE TYPE TO BE USED: vu-dERs OHOSE <br />GROUT SEAL PUMPED: 9 Yes pkOINOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH ZS lc 30 tKy...-1).156LTED TRAFFIC BOX or 1:1 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br />CONSTRUCTION SPECIFICATIONS <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." Contractors hiring or sub- <br />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 />CALL THE VNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REqUIRED INSPECTIONS. <br />VA D VANtrD <br />Signed x /1141411/(4. (46i e) Title/Company Arr. 6:74,CiiS 6fdr3Enl iilet,M$Aer‘bk-L r <br />, <br />Print Name Date 6/ / yOe "14."‘AL J01}11.01tiOnj IA2 <br />SEE SITE MAP IN UNIT !V WORK PLAN DA ED: 23 TA Alff - 2,600 <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE REQUES INVOICE <br />305o, NW g' ---. 14-bos SR# 0023981 <br />1/18/2000 <br />Application Accepted By <br />Grout Inspection By U Date <br />Destruction Inspection By Date <br /> <br />COMMENTS / CONDITIONS: c2iIi1 LOI-41-4-1) /2-4?-4-44-aA