Laserfiche WebLink
9-22-1999 9:26Ar l FROt I <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH•DIVISION ("PHS•EHD") <br /> 304 E. Weber, Third FiOor, Stockton, CA., 35202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR PROM OATS ISSUED <br /> Application is heraby made to San Joaquin County for a permit to construct and/or instali the work described. This application is made in compliance with <br /> San loaqu[n County OeYeso m�Wi Title.Ch ha�ta_r�i11.3 and the standards of San Joaquin County Public�eaitto Services.EnYuAssessofs Healthonmental Division. <br /> �dtwcnt s STec+�TeN �paSZoG Parceltt O-�v <br /> WELL Location Cross Street city <br /> PROPERTY Owner I:.�:�IC(L 3�r•_ <br /> Address i-R;1 N. S�"`�`�•, i City -Tot« zpSs7 Phones: <br /> C-57 Conua�or S U't'�u""^'T Address `lul S I�z(I S tom' _C'ity r ZtQ`iSZS�- r irk U� 5�5�5�Phonal �� 7� ">5� <br /> Address <br /> Consultant l Sub Contractor <br /> City- _l��` Phone# <br /> GIS Coordinates:X <br /> Y Township Range _ Settlor <br /> WORK TO BE PERFOR) ED <br /> -/ "" 11 DESTRUCTION(choose type below) <br /> B N WELL!80RING,' v P HYOROPUNCH.NAND-ANGER OTNER') a OVER-BORE <br /> OIs_80RiNG _ S [J PRESSURE GROUT <br /> WELL# <br /> -Other: <br /> C-tiAMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW OW STEM DIA-OF BORGHOLIw ilea MULTIPLE CASINGS?0 YES a NO WELL CASING CIA: . <br /> a EXTRACTION p AIR Hmmep/ORIVEN CASING THICKNESS TYPE OF CASINGP OBE USE IJ AUGE.RSMEL Ei PVC (I � �HOSc <br /> SEAL I TR-MFE TYPE VAPOR �� >?ROTARY <br /> OEPTH OF GROUT _�. <br /> a MUM FREE-FALL DEPTH 1S 301 <br /> I {]AIR SPARGE �SH POINT GROUT SEAL PUMPED: �Yes 1y�1 <br /> a i�iOTE: MAX] <br /> a SOIL BORING 13 HAND AUGER APPROX.BORING DEPTH 2-v Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> V07HECONOUCTOR CASING PROPOSED? ,v i A,(if YES.rst specification3 here): <br /> COMMENTS; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I I Hereby certify that I have prepared this 3gplication and that the worst will be done in accordance with San Joaquin County Ordinances.State Laws.and Rules <br />` and Regueatians of itte San Joaquin County. Homeowner ar licensed agents signature certi&es the FoNo�rg:"1 rerri7y flsaf in srie performance of the work <br /> for.vhfch this permit is issued,t shall not employ persons subject to WORKMAN,$COMPENSRT7ON Laws of Calffomia_" Contractor's hiring or Sub- <br /> contracting Signature teaMes the f0lkming:`l terrify that in fhe perforr esva of the work for which this permit is issued,I shall employ penins subject to <br /> WORKMAN S COMPEVSA7TON Laws of Calihu»is.' <br /> THE APPLICANT 11AUST GALL 48 HRS IN ADVANCE FOR ALL f2EQtllRl=f]INSPECTIONS. f J <br /> x <br /> i��' Nlli(Zr/ _Et Ti <br /> Signedtle �f�r-r' EN GI I1U c=(Z Oate 12�/�i <br /> SEE SITE MAP ! UNIT IV WORK PLAN DATED <br />'F. EPA ENT USE.ONLY q /Z 3j-0 ! <br /> i. Application Ac4epled By <br /> l f ` Date Issued Area <br /> Grout inspection By Final Inspection By pate <br /> Oestructian Inspection 8y / ate <br /> i <br /> COMMENTS J CONDfTI.ONS: <br /> i; <br /> i FAC#t <br /> E 7PECOOF-S <br /> NTING ONLY. <br /> NLYAID# <br /> FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERivIITISERVICE REQUEST NUMBER INVOICE <br /> i I r'9 .D(} $d <br />