Laserfiche WebLink
f <br /> WELL PERMIT APPLICATION FOkM 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 ) 468-3450 <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 /> covNiY PA " "i ' rr GA RACE E , WE13l R AVECit Assessor's <br /> WELL Location 130 N � HVNTEA STREET Cross Street y STOChTON Zip95202 Parcel# <br /> PROPERTY Owner FACiLITI EG MGMT, DEPT. Addressl171 E . SCOII AVE. City1 EL ON Zip95205 Phone# (209) 468- 3357f <br /> nARP nhA <br /> C-57 ContractorMIYCNPLL DRILLING Address WAD hILA '� 1O WAY City C 0 OV Zip9S610 Lic# 612611 phone# �916) 63l ' 3S $3 <br /> qry <br /> Consultant / Sub Contractor V% A M A 6E 6Ny, Address F, 0 - 8 0 X 8 6 9 City'(1VM h 1 F 1% Lic# St 5 ra Phone# 91611 354-3250 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED <br /> I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> p SOIL BORING # p OVER-BORE <br /> (1) ! WELL # MW ' 1 , MW - 2 n PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: 'TWO ONSITE GROUNDWATER M014110I IN (;- WELL5 <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING II HOLLOW STEM DIA, OF BOREHOLE.1D — &N MULTIPLE CASINGS? 0 YES I NO WELL CASING DIA: 21 N <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCIA 40 TYPE OF CASING: a STEEL I PVC a OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 16 - P T , TREMIE TYPE TO BE USED: J AUGERS OHOSE <br /> p AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: Q Yes J No ( NOTE : MAXIMUM FREE-FALL DEPTH IS 30) <br /> p SOIL BORING U HAND AUGER APPROX. BORING DEPTH _ 3S - P T . I BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? N 0 ( if YES , list specifications here): <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Stale 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 ofthe work <br /> for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 01 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California. " <br /> rXHE PPLICA IT I CAL 8 HRS IN ADVANCE FOR ALL REQUIRED INSPECcTTIIO IS. <br /> Signed x_; AA Tit1e�P.Si/,/ [iJ � Dale J ZAZ— <br /> SEE SITE MAP IN UNIT IV WORKPLAN . DATED RtIlblol <br /> //// DEPARTMENT USE ONLY <br /> � �� <br /> Application Accepted By 1t'iRo4� Date IssueWo/7 /f z Area 41 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> �SL�a 2 G Q05011 <br /> UNIT IV - 6/1/99 /sign bkpg/MI <br />