Laserfiche WebLink
WELL PERMIT APPLICATION FOR UNIT IV <br /> SAN ,lOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ,U� 0 2000 <br /> (209) 468-3449 <br /> E� Hmv <br /> EN�IRONM <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pr �VgISERACES <br /> 1pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is 'd�"in compliance with <br /> tan Joaquin County Development Title,Chapter 99--1J115.3 and the Standards of San Joaquin County Public Health Services,, Environmental a sHealth Division. <br /> jaiO&��a <br /> �t`-" CrossStreet le— L"AitYZIP 5`� Parcet#HELL Location n JfZrf t'V ►'ViyC/ _City lam"+ Zip`7�hone#393�G'J�3ROPERTY Owner ress ( j_&,3? <br /> . f� 7Z76 <br /> ` Z Addres City? �Zip�57`fic# Phone#11� tt��1 <br /> '."57 Contractor A g �// <br /> -'onsultant/Sub Contractor <br /> dress Jy b �,7 Phon ``C(O7 I <br /> 31S Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> <EW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL#i-V 0 PRESSURE GROUT <br /> 'Other: +n/5#/�� ti {�/le-d' <br /> COMMENTS: <br />' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Zat <br /> �� Y O WELL CASING DIA. <br /> �ONETORING OLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS. 0 1=S ,�'�V <br /> EXTRACTION 10%, <br /> AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEELg-PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ff'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:_O OTHER CONDUCTOR CASING PROPOSED? (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,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: "l certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL TH UNIT IV INSPECTOR 48 WORKING HRS 1N ADV NCE FOR ALL REQUIRED INSPECTIONS. <br /> b — <br /> Signed x <br /> I <br /> Print Name Date <br /> SEE SITE:MAP IN UNIT, WORK PLAN DATED =tom. <br /> �,_ -.. . ._ �._... _ .. �....�. _,... . s.... .w_ _. <br /> EPARTMENT USE ONLY <br /> Application Accepted By ! a e ssued _7 `"I Area U 7 5� <br /> Grout Inspection By _ { 1��ig� � Date 7�2f��� —Final Inspection By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS!GONDITIONS. L r -S �- 4a <br /> ACCOUNTING ONLY: AID# <br /> PE OODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> y'` - 07 t C�* 7�f�� s <br /> 1/1812000 <br />