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 andlor 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 s 4�✓0: 4lil �I y6 �� � Cross Street �tf {�� # City G`�_ ;� Zip Parcel# r - ` _GSL —(J <br /> PROPERTY Owner_- 1'\U 1`1 e_� S�Cb l-L�[ Address L�( �J �}/�' f1 l r�cl� City �: - ,I ,Zip G f,( Phone C "7 y45- �7 <br /> G-57 Contractor f n Address t1 �i{�c e'�ct�t41<G! City_ Eyrrihc><��ip(?57Y)Lic# `l9�`l Phone t 5 "?��L <br /> Consultant 1 Sub Contractor J !G G Address t-),1-Q.1 (�!o ity 1�Lic# Phone{���51 t/ � /0(z- <br /> GIS Coordinates.X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> VIEW WELL 1 BORING ( CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> RWELL# MWS w /y W 57 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .;OONiTORING ';B:AOLLOW STEM DIA- OF BOREHOLE 4,'' MULTIPLE CASINGS?0 YES �R O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _�`t TYPE QQOF CASING: 0 STEEL PVC 0 OTHER, <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_- �'�TREMIE TYPE TO BE USED: J�KOGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )R-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 35' .+ kV xOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ACG (if YES, list speclfcations 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: "1 certify that in the performance of the work <br /> for which this permit is issued, 1 shall not employ persons subject to WORKERS'COMPENSATION taws of California." Contractor's hiring or Sub- <br /> contracting signature certifies the following 'Y certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> 'WORKERS'CON,PENSA71ON Laws of Califomia.° <br /> CALL THE UNIT I .INSPECTOR 48 WORKING HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I—? - rr <br /> Signed x Title/Company _ }li# /,CSV /7�1 �—ll�t <br /> Print Name tf7i'IGr� J"i i(�MC�+'t Date �� CSO <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: r ` Zmc <br /> r pEPARTMENT USE ONLY <br /> ` <br /> Application Accepted By - II Date Issued. rJ�1j) l� 3�c:�� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT lnSERVICE REQUEST# INVOICE <br /> SR1 !JIJV <br /> 1/18/2000 <br />