Laserfiche WebLink
WELL vERMIT APPLICATION FOt<M UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 165 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 1__ <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 cor>�p iance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental H€alth Division. <br />Assessor's <br />WELL Location �9;5Joorl`y,-) QJ Cross Street Zip Parcel#_Ciy-- <br />91, <br />PROPERTY OwneC_ &rC/1;1;%4-(0 ?jC,4C'! s, Address M10 (err ­d pit j City C Zip�Phone O` 9�-Z - `ji1%S <br />C-57 ContractorQ&,y)(_P) Address UCOSr IV Ln-, J_Iew WaCity k h Zip`iS Lic# Phone <br />Consultant/ Sub Contractor (, L' Address G1)� Svc � City t o)- Lic# 0 �7 Phone - O /l.Yi6 <br />GIS Coordinates: X , Y Township Range 9 Section <br />WORK TO BE PERFORMED <br />13�NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) v <br />KSOIL BORING #i `� 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />5— <br />COMMENTS: COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />O VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />JJJ'USH POINT <br />"SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMMENTS <br />CONSTRUCTION SPECIFICATIONS ��''^^ .d <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ..ANO WELL CASING DIA: /� <br />CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL t^ ,n i /QTREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes ,$'flo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 75 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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." 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCEFORALL REQUIRED INSPECTIONS. <br />Signed x � j) Title/Company -5' CG14 <br />Print Name P--) l P-) Gy Date - �~ `�+✓"'e,..�e� <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: (ALL . d, i 12-0 S <br />DEPARTMENT USE ONLY <br />Application Accepted By —Date Issued—AreaGid Area <br />Grout Inspection By <br />Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: <br />/ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PER I UEST # <br />INVOICE <br />r — <br />Inc � e <br />�1�A0 o a366y <br />viBiz000 <br />