Laserfiche WebLink
DD <br /> y <br /> I— o WELL PERMIT APPLICATION FORM"-.,.., UNIT IV <br /> _ . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> JAN 3 1 2001 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 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, EnvironmentalAssessor's- <br /> WELL <br /> Health Divisi�- <br /> esso <br /> WELL Location4/(7- ti/��� �� Cross Street City 1V,0,eT7,?;qC11 Zip 9Sr7T Parcel# Z/4-3fr Z5 <br /> PROPERTY Owner[ DCSY�ll Address loco 6' 66.146.1 I-eGCityZip S S" Phone# <br /> C-57 Contractor v iA.t� Acdress /5c-a CLAY SufG 4xCityOAXA4,112 Zip&41Z Lic#!Y6141-00 Phone#$/�- <br /> Consultant/Sub Contractor Address City Lic# Phone# /- <br /> GIS Coordinates.X Y Township TZ 5 Range .Q7G-� Section ,</tt,W <br /> WORK TO BE PERFORMED <br /> -'NEW WELL/BORINGCPT GEOPROBE, HYDROPUNCH,HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type be!ow, <br /> 0 SOIL BORING T 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0HOSE: <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: G'f r 0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here). <br /> COMMENTS: �vLLv' <br /> NOTE: OFFSITE B RING RE A CESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this applicat,on and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and R,;!_s <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 /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CA THE UNIT IV IN EgIOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed xTitle/Company ;�� ems. yr- �1 <br /> Print Name x/ fg X Date /- go. C/ <br /> SEE,-SITE MAP IN UNIT IV...WORK PLAN DATED: <br /> YTMENT USE ONLY ? <br /> Application Accepted By ` ' Date Issued J ���/ Area — <br /> Grout Inspection By Date742� final Inspection By Date_____. <br /> Destruction <br /> ate -- <br /> Destruction Inspection By Date <br /> COMMENTS/CON ITIONS: <br /> G• s �1 <br /> ACCOUNTING ONLY: AID# t <br /> CODES FEE INFO AMOUNT REMITTED CHECK# E Y DATE PERMIT/SERVICE REQUEST#. INVOICE <br /> 3 t I 5R# �oZS� <br />