Laserfiche WebLink
UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES REC[ V ED <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 3 2000 <br /> (209) 468-3449 -EALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 <br /> Public <br /> �Health Services, Environmental Health Division. <br /> / T y ^'� P 5236 Parcel#is <br /> WELL Location 170 6V ' V00444, I Cross[JStreet C��l�'�� Cit Zi <br /> PROPERTY Owner 1 ao""AdddrreeYss/720 W' 70ylMl4 � Cutty � Zip 9.S17oPhone# 7Z+"74163 <br /> C•57 Contractor / µ+`��R� Address3wt YlCityF _ZLic#�0hone# l%��b <br /> Consultant/Sub Contractor4zG Address /u' �S�4y ity Lic# Phone# 4/6 7fft& <br /> GIS 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 /> &WELL# 414.; ' /KW`_ 0PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PONITORING kHOLLOW STEM DIA. OF BOREHOLE i' MULTIPLE CASINGS?O YES ONO WELL CASING DIA:_ <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL a-KC 0 OTHER <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /D ITREMIE TYPE TO BE USED: &AUGERS OHOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes (..No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 3L'rI 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: �� ✓�(�• WE S <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,/shall not employ persons subject to WORKERS'-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 /> WORKERS'COMPENSATION Laws of Califomia." <br /> T E—Hfd IV INSP TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed z Title/Company /Vp / Av G <br /> Print Name �� Date [��Z3/) <br /> SEE SITE M# IN UNIT IV WORK PLAN, DATED: <br /> �` •I rLDEPARTMENT USE ONLY 3 1—.,,�) <br /> Application Accepted By /V Date Issued Area W V I <br /> Grout Inspection By �11C Date Final Inspect n By —Date- <br /> Destruction <br /> ateDestruction Inspection ByI*rIN'Datev <br /> C ME /CONDITION t Y/Ltr QS' <br /> t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC-D By DATE PERMIT/SERVICE REQUEST# INVOICE <br /> $ 0 3 4ZRNDI00Z 42- <br /> 1/18/2000 <br />