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) 468-3450 <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 /> CITY SIDEWALK 11'1 FRONT OF Assessor's <br /> WELLLocalion 00WHVNTERSIRE]ykFT Cross Streett • wtatRAVEcitySTOChtON Zip95701 Parcel# <br /> PROPERTY OwnerFAGIL11M 40 "" ' " <br /> Mrr MTVDEI' 7� Address 1410E ESTOCkTOM Zi, SCOITS AYE , Cit 9 510 <br /> � <br /> y zip tb <br /> (209) ' 8 335 } <br /> RANGI1 0 <br /> C-57 Contractor11116NELL 0KILLIti Address 10618M1LA710WAY CityCORDOYA Zip9S610Lic# 64101— Phone# (916 ) 631 - 3393 <br /> RANcNc R • fr, <br /> Consultant / Sub Contractor RAHArE 1= NV4 Address P: 0 , 13a 'K 869 CityMVRIETA Lle# 58510 Phone# 1916) 354 ^31S0 <br /> GIS Coordinates: X., Y , Township Range Section <br /> WORK TO BE PERFORMED <br /> J NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> 1 WELL # MW - 3 . W - 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: ZWO OFF - S1tt GROV14DWATEI1, MONITORINGWELLS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA. OF BOREHOLE $ _ 1N MULTIPLE CASINGS? 0 YES J NO WELL CASING DIA 7w - IN <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SC It 40 TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I b ' F T . TREMIE TYPE TO BE USED: I AUGERS UHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes J No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 3S ' F T. BOLTED TRAFFIC BOX or U STOVE PIPE <br /> p OTHER: CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications 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, Slate Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 111 certify that in the performance of the work <br /> for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's 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 /> WORKMAN'S COMPENSATION Laws of California. " <br /> H APPLICAN 48 HRS IN ADVANCE FOR ALL RE UIRED INSPECTIO 6. <br /> Signed x /v..� 7 Title i Date Z - <br /> SEESITE MAP IN UNIT IV WORK PLAN . DATED ' biro l o1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByZlkie A-2� Dale Issued��Z; 7ID % , Area o <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS : <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> � S01 t " - S° ; IISR# O o 30 3 Z <br /> UNIT IV - 6/1/99 /sign bkpg/MI <br />