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ORIGMt ; <br /> f <br /> WELL PERMIT APPLICATION F61RM t SITE <br /> SAN AOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION I <br /> ENVIRONMENTAL HEALTH DIVISIO (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA. 96202 <br /> (209) 468-3449 <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 iiescribe'd. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> !i ! 1 Assessor's <br /> Feather River Drive Ci Stockton Zi 95207 Parcel# 118-360-02 <br /> WELL Location Brookside and I-5(Brookside Pump Station) Cross Street City . p <br />[ PROPERTY Owner City of Stockton _Address 2500 Navy Drive City Stockton Zip 95206 Phone# (209)937-8322_ <br /> C-57 Contractor Spectrum Exploration Inc.Address 2365 Wigwam Drive City_Stockton_ Zip 95205 Lic#512268 Phone#(209)465-8712 } <br /> I Consultant 1 Sub Contractor Camp Dresser&Mckee Address 100 Pringle Ave.Ste.300 Cityl WalnutlCreek Lic# Phone#(925)2933-2900 <br /> GIS Coordinates:X 38158146",Y 121020'32",Township T2N Range R6E Secti <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, ND-AUGER,OTHER`) [X]DESTRUCTION(choose type below) <br /> []SOIL BORING# S r [X]OVER-BORE <br /> []WELL# • I Q PRESSURE GROUT <br /> 'Other: Grout Specifications:piezometer will be backfille with bentonite pellets <br /> COMMENTS:Piezometer Bl/PZ-1 will be abandoned 15Y overdrilling with an 8" hollow stem auger rig_Well materials will be <br /> removed and borehole filled to within 3 feet of the surface with bentonite pellets! The top 2 feet of the borehole will be filled with <br /> concrete. I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I i <br /> [X]MONITORING []HOLLOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS?[]YES [X]NO WELL CASING DIA:_2 <br /> []EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS_schedule 40 TYPE OF CASING: []STEEL'{ [X]PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL ! TREMIE TYPE TO BE USED: []AUGERS a HOSE } <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 0 Yes []Nol(NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS- <br /> OTHER:-(] <br /> PECIFICATIONS:OTHER: []OTHER APPROX.BORING DEPTH 41.5 I [X]BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> `COMMENTS: I! <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR JENCkOACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ordinances, R&tjes and Regulations, and a[I applicable CalifornialState laws. <br /> I ) , <br /> Signed x Ti le/Company Ehlf11f40A)Mfr✓tA[- SC IfA/T15T/C DM. <br /> Print Name d "7609 M 1 NAE I E Date <br /> DEPARTMENT USE ONLY f <br /> AA / � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: v I! �� 1 <br /> WORK PLAN DATED; <br /> Application Accepted By S6Date Issued v �I Area <br /> I .0� <br /> Grout Inspection By Date Final Inspectian"B 8�.1� Dated I <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: II <br /> I ! <br /> ACCOUNTING ONLY: AID# cnra <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R <br /> ,W'2LY DATE{ PERMIT/SERVICE REQUEST# INVOICE <br /> D <br />