Laserfiche WebLink
WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />WELLLocation 2085 E. Fremont St. Cross StreetT,aur 1 St City Stockton zip Parcel# <br />PROPERTYOwner MR&MRS Poppi ann Address 1386 P1 Pasent RlCfty StocktoXip 520 hone# 474-0434 <br />31911 W. Ca ttol Av&itySarramPnte 95691'#466270 one#916 371-1690 <br />C-57 Contracto�abPr r�F,■� tants �'� 1P <br />u <br />Consultant/ Sub Contractor WHF INC . Address P.O. BOX 427 City0akdaleLic# Phone,. 848-4280 <br />GIS Coordinates: X Y Township 1 Nn r th Range. 6 Fast Section 3 9. <br />WORK TO BE PERFORMED <br />XNEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below), <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT `� <br />'Other: CPT 1 e <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA'. <br />0 MONITORING <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 EXTRACTION <br />VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: O AUGERS OHOSE C <br />DEPTH IS 30') <br />0 <br />SEAL PUMPED: <br />0 Yes 0 No (NOTE: MAXIMUM FREE -FALL <br />0 AIR SPARGE <br />IKPUSH POINT <br />GROUT <br />H 15 Oft 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPT <br />0 OTHER: CPT 0 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, 1 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 />ATHE - IT I I CTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/Company <br />Signed x- Print NaDate <br />SEE SITE MAP IN UNIT IV I WORK PLAN, DATED: <br />DEPARTMENT USE ONLY <br />Q `L� Date Issued -7 �� Area <br />Application Accepted By Date <br />t 0.; <br />Date Final Inspection By <br />1_LIL�Jt� 1— <br />Grout Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />0-1101 1 5R# 009S A <br />1/18/2000 <br />