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02/23/2001 10:05 2094683433 FIFTH FLOOR ORMNAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL d loo H StlVISION ockton, CA-, 5202) <br />304 E. Weber,h <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />DFF' C��Lm° <br />NON.REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DAIt PP compliance with San <br />application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This a I�, Environmental <br />is me tal He l s <br />Joaquin County Development Title, Chapter X1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Cross Street ZI'Si%ivt City O sne <br />NELL Locatlo �!O c 2 'hone !�( b.J� <br />�jddress V� Gty � ZP <br />PROPERTY Owne� �., _ _ ' /Y �,tz__,?j Lj2li.N0&f.-hon �3 <br />C-57 Contractor`JLIC <br />7Y <br />Ste• Cityl� <br />�Cl <br />2rK <br />AddressIc1� c r r , <br />—Consultant/SubContrSection <br />p <br />Y <br />Township Range <br />GIS Coordinates: X <br />• <br />0 DESTRUCTION (choose type below) <br />WORTO BE PERFORMED_ K <br />0 <br />08E. HYDROPUNCH AND -AUGER, OTHER`) OVER -BORE <br />Q NEW WELL I BORING (CPT, GEOPR0 PRESSURE GROUT <br />a <br />XOIL BORING <br />0 WELL 0 <br />Grout Specifications: <br />� <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSfION S ONS NO WELL CASING DIA: <br />I) _ MULTIPLE CASINGS. Q YES <br />BOREHOLE--�-^_ OTHER: <br />� MONITORING <br />D HOLLOW STEM <br />DIA OF PVC Q <br />TYPE OF CASING: � STEEL � <br />CASING THICKNESS!— DAUGERS 0 HOSE <br />EXTRACTION <br />17 AIR HAMMER/DRIVEN <br />DEPTH OF GROUT SEAL` TREMIE TYPE TO BE USED: <br />FREE -FAIL -DEPTH IS 30 <br />VAPOR <br />1) MUD ROTARY <br />GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM <br />0 AIR SPARGE <br />`SOIL BORING <br />I PUSH POINT <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />p OTHER:,`0 <br />—PPROX. <br />OTHER__--- <br />Ai {YES, list specifications here): <br />CASING PROPOSED?— — <br />CONDUCTOR <br />'COMMENTS: <br />S <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROAE FOR ALL RENT Pt 'Y'll EQUIRED RED INS EC I, <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ApVAN <br />e done in I hereby certify that I have prepared this application and thatthe <br />work ill b <br />State Laws. accordance with San Joaquin <br />Y applicable <br />County Ordinances, Rule�and Regulation , and all a p / ��� �. _Zi.�. <br />� TIUelCompany <br />Signed� x Date <br />Print N <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED. Z� <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />I <br />Y <br />inal Inspection By <br />n /! <br />Ue a 7` <br />D/ <br /># INVOICE <br />RECD BY DATE <br />kCODS FEE INFO AMOUNT REMffTED CHECK �► <br />l'S 9/27/00 <br />C-57 <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit; frier©achmen#-der <br />FEB 23 '01 10:00 2094683433 PAGE.002 <br />