Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICERS CCHWED <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br />304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 9 2000 <br />(209) 468-3449 ENVIRONMENT HEALTH <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 Public Health Services, Environmental a Health Division <br />WELL Location I I IS "�/� `Jtr�� Cross Street A,r sport City 5toGLiOj1 Zip Parcel# <br />Git 1 Ot JTOC ��fO✓I Address �%Z5 (� EI �'r-oao City `:'to�`f00 Zip9SZ02- Phone# 9 <br />PROPERTY Owner �' �" <br />C-57 Contractor V*W v� , �f� Address F0 13ok S City �oy.s-to, Zip `f57) Lic#7200 Phone# 91�I777—�f100 <br />� " Itis t_ona-Pa.ln^, S�ttB <br />Consultant/ Sub Contractor �Tl . 1 t�SOc- c),-tQG Address City UAock2S-to Lic# Phone# 7_0 5 19—ZZz t <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: "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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company Cor,-> -t✓c A {FITC �55 OC SO S <br />Date �o Z`7� 00 <br />Print Name �AAe Q <br />SEE SITE M PIN UNIT IV WORK„ PLAN DATED: <br />DEPARTMENT USE ONLY <br />(o Date Issued /�� Area__ <br />Application Accepted By �s Date <br />Grout Inspection By <br />Date Final Inspection By <br />Destruction Inspection By to ti Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3soZ ������ 3 z CtiF rr oo <br />1/18/2000 <br />Y <br />Township N Range Section ZS <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( <br />DESTRUCTION (choose type below) <br />CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ,I OVER -BORE I WL(I <br />0 SOIL BORING # <br /># <br />XPRESSURE GROUT <br />0 WELL <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />MONITORING <br />0 EXTRACTION <br />HOLLOW <br />O AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />O AUGERS OHOSE <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br />MAXIMUM FREE -FALL DEPTH IS 30' <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: <br />0 BOLTED TRAFFIC BOX or O STOVE PIPE <br />0 SOIL BORING <br />D HAND AUGER <br />APPROX. BORING DEPTH <br />if YES, list specifications here): <br />0 OTHER: <br />OTHER <br />CONDUCTOR CASING PROPOSED? <br />i <br />_O <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: "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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company Cor,-> -t✓c A {FITC �55 OC SO S <br />Date �o Z`7� 00 <br />Print Name �AAe Q <br />SEE SITE M PIN UNIT IV WORK„ PLAN DATED: <br />DEPARTMENT USE ONLY <br />(o Date Issued /�� Area__ <br />Application Accepted By �s Date <br />Grout Inspection By <br />Date Final Inspection By <br />Destruction Inspection By to ti Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3soZ ������ 3 z CtiF rr oo <br />1/18/2000 <br />