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 <br />s� Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental es ealtlth Di/vision. <br />WELL Location 30 l <br />LA- Key t l�VA4-,e1 L.cav� Cross Street s• Let +� City �- oJZip Parcel# �`lTbi L°jl/ <br />�ewro,n Address I" Q• &� 60OLf City +w ^,�^'� ZiP 2 `!i 3Phone# q-. - Bq2 - 8695 <br />PROPERTY Owner / <br />U dw pnll��.R,, �t�G. Address l�.D. [�cyc 5 Cityl�to U15 Zip 9`�n�Lic#72040�J Phone#70��3��" 28ts <br />C-57 Contractor (� / I /� <br />Consultant/ Sub Contractor Cv �lhr.a,n -Q Addres014,1 6o(d, lt�tiq) 6r. City e(-A0`J- Lic#?207er3 Phone#�16� 631-1300 <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL /BORING (CPT, GEOPROBE, HYDROPUNCH, HAND AUGER, OTHER') DESTRUCTION (choose type below) <br />0 OVER -BORE <br />VV \\ a SOIL BORING # 0 PRESSURE GROUT <br />D WELL # M W - <br />*Other:11 <br />II <br />v�� k 3 5-j lv C1 Y '( van work �� C" MQr�t n �V6�� <br />COMME <br />TYPE OF WELL INSTALLATION TYPE 'CONSTRUCTION SPt_UHUA i 1UN <br />MONITORING tKHOLLOW STEM DIA. OF BOREHOLE S � MULTIPLE CASINGS? 0 YES J�NO WELL CASING DIA: 2 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <br />• �rU TYPE OF CASING: 0 STEELVC 0 OTHER: <br />S <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: tKAUGERS DHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH %S <br />OLTED TRAFFIC BOX or 0 STOVE PIPE <br />D OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />one in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />I hereby certify that I have prepared this application and that the work will be d <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 />=%,,� LICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signedx- Title c�eo �ay t5 Date 7 — 2006 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY Lop dU 4 <br />Date Issued Area <br />Application Accepted By Z Date r70 <br />Grout Inspection By Date Ob Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: n <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # I REC'D BY I DATE <br />9 6,6, <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE & <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />0 <br />G .0.L. <br />PERMIT I SERVICE REQUEST It I INVOICE <br />CONII'ENSATION DECLARATION <br />