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 />/ r Assessor's nR` <br />WELL Location 30 1 W - �``e"hna.h LCT Cross Street S• Lee V -- City L, o� � Zip G Parcel# L <br />PROPERTY Owner// Ct evroyt Address P.0 .2) r-\ L6o / City 1�w l�c�rnan Zip -14583.)Phone# 92-8112-8'9S <br />C-57 Contractor V% W OfId 1lv 5 IAC. Address rJ�K / CityRIO V15d'r, Zip C14�ILic#-7��O7Phone#7c'7-r4-2SIS <br />Consultant/SubContractor6e-4 C-Rt,AT Vx Address3(gq 64 G.,,q D,• city Lic#226-7R3 Phone#q(/ 631-13cm <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # Mw �'f V `w'E5 0 PRESSURE GROUT <br />'Other: <br />COMMENTS:As S",� to C a.',r , 11- 11-22 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />"ONITORING HOLLOW STEM DIA. OF BOREHOLE S q MULTIPLE CASINGS? 0 YES ,110 WELL CASING DIA: Z <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSc D TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'S I TREMIE TYPE TO BE USED: ZO$ AUGERS OHOSE <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 -75 r *OLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? ( 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: "I 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: "1 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 />I NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />TH PP <br />Signed x Title <br />Date 1- -7 r 20c0 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date Issued 1' JD AreaL-0n U� <br />Grout Inspection By Date Z- OV Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: W �V <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br />p o ro t- ILI ov SR 0o2 -1b <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />