Laserfiche WebLink
1-1 NOW <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> V�F <br /> rV JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r: <br /> VIRONMENTAL HEALTH DIVISION ( PHS-EHD") I N AL <br /> DEC 2 81999 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> OR100 <br /> (209) 468-3450 <br /> �� ;-I- ' SR' ICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Aoplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance wit". <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> �`vp ca•n+ 1 Clvp 6IL D. ` Assessor's <br /> WELL Location 65(y �� n�C=LLL�1�._._CrossStreet MiSSs-,:, dD amity S�a�IC j"n Zio� Parcet# <br /> PROPERTY Owner. 1� <br /> L �c(" Addressy2G W. yoS�Vl'1if�&ecjty H1�nll�ct� Zip�'��Phone# 2' c(`✓SL7-7c <br /> IIS �ity <br /> Z 0 ujV -2j c�A-,G % �L <br /> C-57 Contractor a ;AtAcb n,; ��nfFAdress A <br /> /Sub Contractor M 4C 4,e IL ZnAddress fXb(nc S • yV L.p n�•r CitySc rc Mca��Li 1 2- t Phoned <br /> :SIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NAND-AUGER.OTHER-) <br /> iEW WELL!BORING (CPT, GEOPROBE.HYDROPUNCH, D DESTRUCTION (choose type below) <br /> D OVER-BORE <br /> / D SOIL BORING �J D PRESSURE GROU7 <br /> D WELL» >`'vet" I � rVi,�'- Z , iv1 M'.. -;��U"', . <br /> -Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS WELL CASING CIA: <br /> MONITORING OL'_OW STEM DIA. OF 30RENOLE S-inc,1� MULTIPLE CASINGS? DYES11 <br /> _ RACTION IR HAMMER/DRWEHN CASING THICKNESS � .,iz I 0 TYPE OF CASING: D STEEL 'PVC D OTHER: <br /> VAPORD MUD ROTARY DEPTH OF GROUT SEAL I- 6 17bo V TREMIE TYPE TO BE USED. _IkAUGERS D~CS= <br /> 7 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER APPROX. BORING DEPTH ^7n • F�`' OLTED TRAFFIC BOX or D STOVE P!?= <br /> '? OTHER: <br /> CONDUCTOR CASING PROPOSED r if ES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify:hat I have prepared this application and that the worK will be(lone in accorcance with San Joaquin County Ordinances, State Laws, ane :=cines <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 /> `or which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's h'h'c- Cr sutr <br /> ,ontracting signature certifies the following: 'I cenify,that in the performance of the work for wnicn this permit is issued. I snail employ persons subject to <br /> vVORKMAN'S COMPENSATION Laws of Califomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVAN OR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> Title ' Date 5 5 <br /> SEE <br /> SITE nM N UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLYT6 <br /> Aoolication Accepted By <br /> Date Issued � (� Area <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Insoection By Date - <br /> COMMENTS I CONDITIONS: ja drx)11, <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO ` AMOUNT REMITTED CHECK:,/CASH ( RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICEyn �I ! , t� C� l7a2, �00 <br /> UNIT IV- 5/99/MI <br />