Laserfiche WebLink
4, <br />WELL PERMIT APPLICATION FORM <br /> <br />UNIT IV <br />RECEipdt <br />JUL 2 9 2002 <br />ENVIROW :NT HEALTH p folnr,rn NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application i heYebYlikillskiEtbi 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 .<C0 V .'C-z4c1r. 1)%4Coaa Cross Street le.t..1c..1%-cti WI City Z-00( ; zipc152.510 Parcel#041 - 32_ <br />0 <br />C-57 Contractor 1:1-;1(f..1 Address /40e-A.Je- 'P-..d. City frtg,r41',6e2-Zip9efLicitti<C6165 Phone#(925 31Z <br />14.6 <br />C <br />Consultant I Sub ContractorCavrti&r-l'o1/4.4rnc..;reAmakdress Z70 Pit.r1‹,•4s 64, City--<0')orl-C\ Lic# ‘47/2.4 Phone#(.704. 9a5-zits:, •(--," <br />GIS Coordinates: X Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED <br />')ItNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER*) <br />j] SOIL BORING # <br />*WELL # _s-1/AL <br />fl DESTRUCTION (choose type below) <br />O OVER-BORE <br />O PRESSURE GROUT 1 <br />*Other: <br /> <br />COMMENTS: <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 />04) <br />PROPERTY Ownee-t £ ;e.rprIreCier&111-.. Address zcseict 44-2R-il Aoe. citycw-mkr.o..do Zip1S.Sz4 Phone# 31Si -2/40 <br />TYPE OF WELL INSTALLATION TYPE <br />7010NITORING /a:HOLLOW STEM <br />o EXTRACTION fl AIR HAMMER/DRIVEN <br />0 VAPOR C MUD ROTARY <br />fl AIR SPARGE 1:1 PUSH POINT <br />O SOIL BORING fi HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS a <br />DIA. OF BOREHOLE (0 '1(17,41 MULTIPLE CASINGS? a YES NO WELL CASING DIATI <br />CASING THICKNESS SC. 4.1cD TYPE OF CASING: fi STEEL [rPVC a OTHER: <br />DEPTH OF GROUT SEAL "4- 410 TREMIE TYPE TO BE USED: fi AUGERS )31-10SE <br />GROUT SEAL PUMPED: 0 Yes fi No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH / 31C:BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED') A/C. ( 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: "/ 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: "/ 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 UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company•Slet P` ¢-0•'s-11 C.-ar-v,)A1-1"0. <br />Print Name -6,70' '70 /144 rr-) re)4 tc Date <br />"10.Pr.... <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />14fit„ <br />PARTMENT USE ONLY <br />Date Issued <br />Final Inspection By <br />0 <br />11) <br />Area <br />Date 576 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D A Y DATE PERMIT / SERVICE REQUEST # INVOICE <br />I • c0 iffiffrir gilic- <br />I -Inn?, <br />: : ,)O <br /> <br />4 /441 <br />N