Laserfiche WebLink
U N!T !V <br /> WELL PERMIT APPLICATION FORM <br /> F�)EC <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER S iv <br /> E© <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) SAN 2QQ4 <br /> r) 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON REFUNDABLE PERMIT EXPIRES'i YEAR FROM DATE ISSUED PERMIT/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 /> 7 Assessor <br /> WELL Location,410 a 1 4� Cross Street "S IS_ City �,ap Tfzza Zip�55SJ Parcel" <br /> PROPERTY Owner :k1 ✓!�2J r 111 Address 3 Q;Ct City {, Zip 25�23 Phone# <br /> C-57 ConiraCor Dr �s � Addr <br /> ess <br /> C Gdy l'1 ' / Zipq� Lic#� 5� Phone#�Z�3rf - r� <br /> Consultant/Sub Contractor� '., '7 Er1V fL'f! _ Address7��1� �✓><�"'L�� _CitYLusKI`u'�L Lic# Phone#SSQ �'Z <br /> � <br /> LW <br /> GIS Coordinates X Y Towoship Range Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL/BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING#Z p OVER-BORE <br /> �]WELL# ©PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA OF BOR:HOLE`}nnn MULTIPLE CASINGS1 a YES [j NO WELL CASING DIA <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS!Wq TYPE OF CASING a STEEL 0 PVC 0 OTHER <br /> E VAPOR '26UD ROTARY DEPTH OF GROUT SEAL f SL __TREMIE TYPE TO BE USED []AUGERS VOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED `, Yes f No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'N-�01L BORING 0 HAND AUGER APPROX BORING DEPTH ��c�f �BOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> p OTHER 0 OTHER CONDUCTOR CASING PROPOSED? /LC (if YES list specifications here) <br /> COMMENTS ZrlrG'^_'"1__ <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 Regulat:ons of the San Joaquin County Homeowner or licensed agent s signature certifies the following '7 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" Contractors 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 /> WORKERS COMPENSATION Laws of California ' <br /> L](j 7 7 J <br /> Signed x �� s � _, Title <br /> �i✓j J I�_ Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED- -/v <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_iLLi� ( c'��� r� Date Issued 2 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 so 5r3 UU S ! <br /> UNIT IV-6/23/99/sign bkpg/MI <br />