Laserfiche WebLink
WELL PERMIT APPLICATION MRMUNIT 1, <br /> EGF- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICd� I V& <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SAN 1 3 2000 <br /> (209) 468-3449 ENVIRCiNMElN7A�1_ HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER3M11T / SERVICES <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 /> � —�- /a_37 Assessor's <br /> WELL Location 411-e Cross Street �� City // Zip"/ Parcet# <br /> PROPERTY Owner F-0 p, Chu; Address_7�5 14k2)_44 y?-g, Y Zi Cit � J -) <br /> .� _ p�a3 hone# <br /> ctor -eV� ' Address?/,3li <br /> J_CitySl4G Zip��,,�� Li �''f/s�'Phone#' Z2Z Z <br /> Consultant/ ub Contractor --1 Address `IV,GtiNs��; CityLic# Phone# y&-7 <br /> GIS-Coordinates_X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER`) STRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Ell MULTIPLE CASINGS?0 YES k1lO WELL CASING DIA:Z11 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ,VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �27 f TREMIE TYPE TO BE USED: 0 AUGERS DHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )?,Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 060 ' <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> r <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,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 1 certify 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 /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title47-=id w J 5f" Date <br /> ASEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY r� <br /> Application Accepted By Date Issued I 7l9 d Area 7 2__ <br /> Grout Inspection By I - <br /> Date Final Inspection By Date <br /> Destruction Inspection By �� Date f`2g J6 d 11/l. Yt LPLf3 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 8Y DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />