Laserfiche WebLink
WELL PERMIT APPLICATION FvRM UNIT IV <br /> SAPF JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <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 Tale,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessor's <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Owner Address City Zip Phone# <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Contractor Address City Lica Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> a NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> p SOIL BORING# Q OVER-BORE <br /> p WELL# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?p YES Q NO WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 7YPE OF CASING: 0 STEEL a PVC a OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT, SEAL PUMPED: fa Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER: CONDUCTOR CASING PROPOSED' (if YES. list specmcations 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: "I 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 /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Insoection By Date <br /> COMMENTS/CONDITIONS: <br /> FAG: <br /> ACCOUNTING ONLY: AID# <br /> I <br /> i PE CODES FEE INFO I AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> UNIT IV-5/99/MI <br />