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WELD PERMIT APPLICATION F,.-AM UNIT IV <br /> - <br /> SAN JOAQUIN COUNTY PUB-LIC HEALTH SERVICES <br /> OCT 2 3 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD n,•^ <br /> 304 E. Weber, Third Floor, S+ockton, CA., 95202 L. , <br /> __NViRJi aV,Li 3* HEALTH <br /> (209) 468-3449 - <br /> PER°,r'iiT/'SERVI CES <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 wlth San <br /> Joaquin County Developpme'nt`Titie,Chapter 9-1115.3 and the Standards of San Joaquin County Pubtic Health Services.Environmental Health Division. <br /> WELL LocafionJAb1 W•rnQy6p�jlf�&At/� Cross Street Cl Assessor's <br /> ��^ ry � zip g5dQa P,,",# IIA- I4�-Oa. <br /> PROPERTY Uvner-�dritJKSr4.1df u+�t4\ddress Ae�l Pae4y_ A tt. CityS* U'_)i ► ZiP��b1 Phoneri q(,P- $1t1 <br /> Cf57 Contractor - ' 7 ddress lLft5. CitYSC�j M ,,,�Ztpge g ; O�Phonett'�IO'237-b-7:5 <br /> Consuttant/Sub ContractorO;�Yy� Address_1M Un:f <br /> 'bO gGhC(.fKjae• hc�F Phone# ,�5�i4��$pp <br /> tt• tSa <br /> GIS Coordinates.X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> AEW WELL!BORING(CPT, OPROBE, YAND-AUGER,OTHER-) [}DESTRUCTION(choose type below) <br /> WGOIL BORING# %DROPN <br /> ,a�tVELL#_ 6} [IOVER-t30RE <br /> 'Other: I]PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE�-.S ttr�MULTIPLE CASINGS7`�'4ES Q NO WELL CASING DtAQ1$r� <br /> 0 EXTRACTION Il AIR HAMNIER/DRIVEN CASING THICKNESS yO N TYPE OF CASING: O STEEL GA6VC G OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED: GAUGERS pHOSE <br /> 0 AIR SPARGE BUSH POINT GROUT SEAL PUMPED: p Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> +SOIL BORING p HAND AUGER APPROX.BORING DEPTH_-A5 Gt! WO <br /> �'R Q40LTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER--[I OTHER CONDUCTOR CASING PROPOSED? �11 <br /> ( 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 Cone in accordance with San Joaquin County Ordinances.State Laws,and Rulss <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's Signature certifies the following:'4 certfry that in the performance of the work <br /> for which this permit is issued,f shall not employ persons subject to WORKERS'COMPENSA TTON Laws of Cafffomia^ Contractor's hiring or sub- <br /> contracting signature certtfles the following:7 certify that In the performance of the work for which this permit is issued,1 shall employ persons subject to <br /> WORKERS'COMPENSA 77ON Laws of CalrTomla.' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x TidelCompany_ �� <br /> Print Name ��(�� � SFA�Qc v\ Date <br /> Uy\ J P_x%:, y a� � Pa a�z..,UO'(% w_rn2✓�bou w AJe- <br /> SITE FILE ADDRESSMORK PLAN DATE: Grou�.L�.��ehr ty�nni�o_ c_ �W�\-x�..c+,atlu.+�.�'0` p1 h <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Oate IssuedZ O i Area <br /> Grout Irtspectlon BY , rte L Oate D L Final Inspection By Gt M a.e1( Oate 1 y <br /> Destruction Inspection By Date <br /> COMMENTS J CONDITIONS: K ` <br /> ACCOUNTING ONLY: �AMQUNT <br /> PE CODES FEE INFO rrrED CHECK# REC'O BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o <br /> 1 SRft 7- <br /> C-57 tXp` WC/Waiver_ C-57 Letter of Authorization to sign permit_Encroachment doc(s). 5/17/00 <br />