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�.��1H �.,� .pan Joaquin Coun REWIVED, <br /> Ate- •,-. 9 tY <br /> Environmental Health DepartnAM 0 4 2004 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stocktonl T VICES HEALTH MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.se UNIT IV <br /> Well Permit Application <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 with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 500 West Hospital Road Cross Street S. Manthey Rd.City French Camp Zjp 95231 Parcel# 193-050-08 <br /> PROPERTY <br /> Owner San Joaquin General Hospital Address 500 West Hospital Road City French camp Zip 95231 phone# (209)468 6000 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr Clayton Group Services Address 6920 Koll Center Parkway,Suite 200 City Pleasanton.CA LjC# Phone# 925-426-2600 <br /> GIS Coordinates:X 37.8850 Y tzl.zaso Township 1 North Range 6 East Section 35 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 E ER UCTIRE. D (choose type below) <br /> x 0 SOIL BORING# SB1 to SB5 0 O <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: Five shadow soil borings will be advanced using a hand auger.After soil samples are collected,the borings will be backfilled with neat cement grout. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE N/A 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N/A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL up to 4 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes x 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )U SOIL BORING X 0 HAND AUGER GROUT SPECIFICATIONS neat cement with free fall of up to 4 feet <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 4 feet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS' Five shallow soil borings will be advanced using a hand auger to collect grab soil samples. After soil samples are collected,the borings will be backfilled with neat cement grout <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Title/Company Senior Project Manager/Clayton Group Services <br /> Signed x I <br /> Print Name Michael J.Zimmerman,PE, EA Date <br /> DEPARTMENT USE ONLY ��G1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �,tNt <br /> OUNN TPS <br /> p I Dv/ ROPNpB <br /> Q1 1 1/�►J �(tn- Date Issued 15AO Ft <br /> Application Accepted By —11 pE <br /> Grout Inspection By Date Final Inspection By Date SN <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC#60000 9(0 - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />