Laserfiche WebLink
WELL PERMIT APPLICATION FvRM UNIT IV <br /> SAt4 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 Title,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 /> 1-57 Contractor Address City Zip LiG Phone# <br /> onsultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH. HAND-AUGER. OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# 0 CVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other. <br /> CCMMENTS: <br /> -YPE OF WELL CONSTRUCTION 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 HAMMERJDRIVEN CASING THICKNESS TYPE OF CASING. 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 H 0 S E: <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: CONDUCT OR CASING PROPOSED (if YES. list specifications nere): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> nereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. State Laws, and Ruies <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, l shall not employ persons subject to WORKMAN'S COMPENSA7ON Laws of Ca/ifomia." Contractor's hiring or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work for wnicn 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 I CONDITIONS: <br /> r"AC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK-,/CASHI RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S R# <br /> UNIT IV- 5/99 /MI <br />