Laserfiche WebLink
Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <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 />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 Al 54- .630 ' A1der S arce 4--) Cross Street 11:,-,c-t& Ave City 54-6.tA(.4-zan Zip 5 20 Z Pl# I 27-050- <br />C0,7 14,11 City cicl-c.." Zip 9Z2.. Phone# (201) 937- 33‘49' <br />cityRc.x.i.cLecvgip q5-7412Lic# 711510 Phone# (611) g 38 -110 <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br />\k1 <br /> <br />WORK TO BE PERFORMED <br />!XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />fl SOIL BORING # <br />gVVELL IsA1,-)-11 <br />O DESTRUCTION (choose type below) <br />fl OVER-BORE <br />PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />PROPERTY Owner (II-77 of 51-ocis ,1-0 Address <br />C-57 Contractor Cc-secztra an Ilivs-.3 Address 3'i2 C- C r•C- lf_ <br />044e-4-- <br />Consultant / Sub Contractor 6c4te! co Lc/ Address 3 I 6 ,-/ Dr, 170 City&Ac.L. jLic# C 77 Phone#(ci16 ) 631 - 1300 <br />TYPE OF WELL INSTALLATION TYPE <br />VMONITORING NI/HOLLOW STEM <br />U EXTRACTION fl AIR HAMMER/DRIVEN <br />1:1 VAPOR flMUDROTARY <br />a AIR SPARGE U PUSH POINT <br />SOIL BORING a HAND AUGER <br />U OTHER OTHER <br />CONSTRUCTION SPECIFICATIONS -7 ,i''. <br />DIA. OF BOREHOLE 8° MULTIPLE CASINGS? 0 YES 1KNO WELL CASING DIA: < Ns. <br />CASING THICKNESS 5c.L. 1-10 TYPE OF CASING: 0 STEEL 'VC 0 OTHER: <br />DEPTH OF GROUT SEAL 7S ' TREMIE TYPE TO BE USED: 0 AUGERS 0-10SE <br />GROUT SEAL PUMPED: tirees p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')7:44 <br />APPROX. BORING DEPTH i0 ' XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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 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 />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 Laws of California." <br />TH P C T MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title Pro-,.serc - GeoL-5,4-Date C(S /6 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />Date Issued 5 /1 6 / <br />DEPARTMENT USE ONLY <br />Lc)-(sfro./\ <br />Date <br />Date <br /> <br />Final Inspection By <br /> <br />COMMENTS / CONDITIONS: <br />',VV./S..04,1M 11.•,—, <br />PE CODES <br />••••• ••= • • <br />FEE INFO <br />. <br />AMOUNT REMITTED CHECK # <br />I hAc.;g <br />REC'D BY DATE PE -.......-.-a....---1' QUEST # INVOICE <br />50 <br />4 <br />sa. COS 8 . <br />_ --- -...... ....., ... • <br /> . f lit, 0 <br />.--....-..• A•T•T•1 \ Tc, A ,T.Tr-VVICT Tr' cr'r AD A -rirym <br />C-57 LICENSED CONTRACTOR MUST SIGN <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Signed x <br />(o <br />Area <br />Date