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I COPY <br /> WELL PERMIT APPLICATION FOM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ZOO S$5 <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 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 /> Assessor's <br /> WELL Location 1904 West Charter Way Cross Street Fresno Ave. City Stockton Zip 95206 Parcel#: 163-020-17 <br /> PROPERTY Owner: Occidental Chemical Corporation Address: 360 Rainbow Blvd. City: Niagara Falls,NY Zip: 14303 Phone#: <br /> C-57 Contractor:Fisch Environmental Address: 399 Sheri's Place City: Valley Springs.CA Zip: 95252 Lic#: 683865 Phone#: (209)772-3570 <br /> Consultant/Sub Cntr: Geomatrix Consultants,Inc. Address: 1281 E.Alluvial Ave..Ste. 101 City: Fresno,CA Lic#: Phone#: (559)264-2535 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION(choose type below) <br /> [X]SOIL BORING#5 direct-push D OVER-BORE <br /> D WELL# D PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3 inches MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> [X]SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: Bentonite <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 5.5 feet 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: Soil borings advanced with direct-push ria for soil samplino. Boring will be backfilled with bentonite. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT 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 San Joaquin <br /> County Ordina/Icq�, F�Aegdgid RP4ulations, and all applicable California State Laws. <br /> Signed x /GpPixnd,'U$��/ j('(/IWH/� Title/Company: Project Engineer,Geomatrix Consultants,Inc. <br /> Print Name: Scott J.Hatton _ Date: April 1&2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: jG 6�/ <br /> WORK PLAN DATED: v1u .mac 2A02— <br /> Application Accepted By Date Issued_ Areae <br /> Grout Inspection By j6ate Final Inspection By - " Date /0'LG'07 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 210 � /1912 /? p o3 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc IV 1/25/02 <br /> I:GS000st5352.000\Document\Field SAPs\5352-WeI1PermilApp.doc <br />