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02/23/2001 10:05 2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL Floe H StlVISION ockton, GA., 5202) <br />304 E- Weber, Third <br />(209) 468-3449 <br />NON-REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DATE ISSU D <br />application is hereby made to San Joaquin County for and the Standards of a and t r1suint County Public the work abed ServiceThis s Etnvironmental Health <br />eal SlDivision. <br />San <br />Joaquin County Development Title, Chapter 4l 115.3 a S Zip��Pyrceli+! pp���/p <br />�2(p <br />CA <br />Cross Street -H <br />HELL Locatlo ) / <br />Al S'/-h�n��if r^;nr�'(tttKT�=�'�—zip <br />a _Phone# <br />PROPERTY Owner - I}` Lk '` Address T <br />PhoneA . <br />AddressZ�— <br />C-57 Contractor ��� - } I PhoneYf-S- <br />_Address_, '1'- Lic31�� _. <br />Consultant / Sub Contractor Section <br />GIS Coordinates: X Y <br />Township Range . <br />WO K TO SE PERFOR D: DESTRUCTIONn( hOoreOVERtype <br />below) <br />0 NEW WELL / BORING (CPT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER? p PRESSURE GROUT <br />BORE <br />j'SOIL BORING a <br />p WELL # Grout Specifications: r <br />'Other: <br />COMMENTS: <br />TYPE OF WE L <br />INSTALLATION TYPE <br />MONITORING <br />Q HOLLOW STEM <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />VAPOR <br />0 MUD ROTARY <br />AIR SPARGE <br />0 PUSH POINT <br />CONSTRUCTION SPECIFICATIONS <br />MULTIPLE CASINGS? � YES 0 NO WELL CASING DIA: <br />DIA OF BOREHOLSj PVC <br />p OTHER: <br />TYPE OF CASING: 0 STEEL 0 HOSE <br />DEPTH OF GROUT SEAL, <br />CASING THICKNESS TREMIE TYPE TO BE USED: p AUGERS p <br />OTE: MAXIMUM FREE -FALL- DEPTH IS 30') <br />GROUT SEAL PUMPED: 0 Yes p No (N <br />CIFICATIONS <br />GROUT SPE <br />Q BOLTED TRAFFIC BOX or 0 STOVE PIP <br />� SOIL BORING D HAND AUGER <br />p OTHER: 0 OTHER__� APPROX. BORING DEPTH — <br />(if YES, list specifications here): <br />CONDUCTOR CASING PROPOSED? _ <br />NT <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR E FOR ALL HME RE RED NS PERMITS. ONS <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS INADVANCE <br />I hereby certify that I have prepared this application and that the work ill be done in Laws. accordance with San Joaquin <br />Y applicable / <br />County Ordinance ules and Regulations, and all a p ��c .�� "! <br />TIUelCompany — <br />Signed x Date <br />Print Name ` n�onRTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 3 " 2--0 1 <br />Application Accepted By <br />C-57•^ WCC WAIVER_ <br />C-7 / Lel I er -I -. . <br />Final Inspection By <br />FEB 23 '01 10:00 2094603433 PAGE.002 <br />