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WELD 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) 468-3450 <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 descnbed. 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 Health Division <br />Assessor's <br />NELL Location/ l SLti. (Dt�14✓'C Cross Street Sf City Zip 1�Cs 32 Parcel# AA <br />PROPERTY Owner/'��/1 �t�,cl�� .1rc Address�I/1� ��5/ur �Ciry ZipZQPhone#�S� �y 3 <br />-57 Contractor t . Address tROl�, ap, rJ' Ciryk'Zip &D�Lic#ULiEdkPhone# y/L-7.2.2 <br />Consultant / Sub Contractor. Acid ress. p42 KJ City&l%�Lic# • � Phone#.?,04 592 WV <br />31S Coordinates: X • Y <br />WORK TO BE PERFORMED <br />Township Range <br />NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER') <br />,SOIL BORING # y_T•L(1 tier �+. <br />n WELL 9 <br />Section <br />i <br />t � 1 <br />0 DESTRUCTION (choose type below) <br />0 OVER-80RE <br />0 PRESSURE GROUT ((� <br />'Other. ,` "': \ R <br />COMMENTS: <br />1'PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS 5a<. Coj- <br />] MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0HOSE <br />3 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />,ASOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPs <br />0 OTHER: CONDUCTOR CASING PROPOSED' (if YES. list specifications here). 7 <br />COMMENTS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />hereby certify that I nave prepared this application and that the worn 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 tollowing: "/ certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sur} <br />Lontracting signature certifies the following: 't certirY that in the prrformance of the wbec for wnrcn this permit ,s issueC, i spall employ persons subject to <br />WORKMAN'S COMPENSATION Laws Of California.' <br />T APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x40 <br />Title " Y-i4e rc Date r' /1, - 2 <br />SEE SITE MAP IN, UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued_ 1 I O C7 Area <br />(/' <br />,�[^G-� Date a$ OO Final Inspection By Date <br />Srout Inspection By . <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK#/CASH <br />UNIT IV - 5/99 /MI <br />RECEIVED BY I DATE I PERMITIS <br />NUMBER I INVOICE <br />