Laserfiche WebLink
Application Accepted By —111 • <br />Grout Inspection By <br />Destruction Inspection By <br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <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 164 6- Pae‘Ac Avert ve- Cross Street (e-1..1r,tA- SA- City Sk.ebe.14. i'SVN Zip q5-2-t>2. Parcel# 11 7 - 020 - 3( <br />t-Crafj <br />PROPERTY Owner(*ete a <br />c, <br />Address 43.04-44 e-K tra Cityfri-64msvc-• Zi0014•15hone# cilEr - 714- 3246 <br />C-57 Contractor 11--44.4....c. '01.t• \\Vv.) Address r-PO \-;a14 *.3 City Ro 'Jim Zip 4511 Lic# 710171 Phone# 707- 3744-‘130v <br />12 4.41hn.c... Re.o.c,lA0 <br />Consultant/Sub Contractor 0.01, '4 tler 1.45 Address -31140 Gdia CO. Dr, 170 City Car-dove. Lic# 12 1 1 Phone# gib- 631- J3erv <br />GIS Coordinates: X ,Y Township Range Section <br />-EPT+9--en1-111"nrikive Po Box 1060 cAt <br />WORK TO BE PERFORMED <br />"O\NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # <br />(WELL # SP -164 ,8,C); 'SP -2(4.8.c); 5P- 3(A,8) <br />*Other: <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />OVER-BORE <br />a PRESSURE GROUT <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />tiZMONITORING 114HOLLOW STEM <br />EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR UMUDROTARY <br /> <br />a AIR SPARGE a PUSH POINT <br /> <br />U SOIL BORING a HAND AUGER <br />OTHER 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 " MULTIPLE CASINGS? U YES NO WELL CASING DIA: '1 <br />CASING THICKNESS 54,1,, Lie) TYPE OF CASING: STEEL lePVC a OTHER: <br />DEPTH OF GROUT SEAL 2'5 ‘/.44 183 TREMIE TYPE TO BE USED: a AUGERS Ift-i0SE <br />GROUT SEAL PUMPED: RYes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 3e7'64:51 / 961 1KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <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: "1 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 Laws of California." <br />T AP ICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title cerm or 6 e.01:.5 L54-- Date /i 3 Az- <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: De-c-e,,, 6ex lt 2cra <br />Signed x <br />DEPARTMENT USE ONLY <br />Date Issued .2 _ Area <br />Date3 Final Inspection By —771 - Date 3 <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: Al D# <br />INVOICE <br />PE CODES FEE INFO <br />5 t 3 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />35b „ps8 <br />AMOUNT REMITTED CHECK # <br />FAC# <br />REC'D BY DATE PERMIT / SERVICE REQUEST # <br />4'cgcle SR# ?3 <br />00.-_5061q