Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD © l' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILUCOPT <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standar of SanJoaquin County Public Health Services,Environmental Health Divi *on. <br /> Assessor's <br /> WELL Location �• fj)ZKJ A Cross Stre! city lip ly Parcel# r/y� <br /> PROPERTY Owner Mr 0LI VA l9 7 Address 4 a7G 1D. 1J//GO--�ity 5 ' ip T Phone# J <br /> C-57 Contractor Address - �,U wAl� City Y��G '�'�V ipT��� ic# Phone# oy <br /> Consultant/Sub Contractor s C1. �t�]`tI7fx&,dZQss 1 ?93 S4e9 ityLic#[fOTZP.^Phone#.7'W//8- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> n SOILBORING# MAR ( '=E <br /> I-TVELL# J-( _ 7 S.NLLJ NW P E GROUT <br /> 'Other: .r f:'_'!:IV( JG i��iLl <br /> COMMENTS: PERPI! SE /IULS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff"MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0Irtt MULTIPLE CASINGS?H YES kl<' WELL CASING DIA: Z�f <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL 0�r< Q OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 11A ej g,5 TREMIE TYPE TO BE USED: O AUGERS jp-t&SE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: &'res• p No (NOTE: I MIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER APPROX.BORING DEPTH /I //D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS a - <br /> � <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." Contractors 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 Califomia." <br /> * LTH V 1 PECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/Company ' <br /> Print Name FlL(J[ �L �� V Date 3 L Q [ <br /> SITE FILE ADDRESS/WORK PLAN DATE: 30-o A LI b <br /> DEPA--_j6,,RTMENT USE ONLY p d <br /> Date Issued_ 0 —p I Area 06 <br /> Application Accepted By <br /> 0 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o 3 z8 <br /> C-57 exp. WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />