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FIE Copy <br /> �nI WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> f <br /> 5 y f (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 /> Assessors <br /> WELL Location 1904 w Charter Way Cross Street Fresno Ave. City Stockton Zip 95206 Parcel# 163-020-17 <br /> PROPERTY Owner_Occidental Chemical Corn Address 360 Rainbow Blvd City_Niaeam Falls Zip 14303 Phone# <br /> C-57 Contractor Fisch Environmental Address 399 Sheri's Place City Vallev Springs Zip 95252 Lick683865 Phone# 209-772-3570 <br /> Consultant/Sub Cntr Geomatrix Consultants Address 2444 Main St.Ste 215 City Fesno 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') []DESTRUCTION (choose type below) <br /> [X]SOIL BORING# 5 []OVER-BORE. DIAMETER <br /> [j WELL It []PRESSURE GROUT <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI TC,/A IONS <br /> [j MONITORING []HOLLOW STEM DIA.OF BOREHOLE (. []MULTIPLE CASINGS []MULTI-LEVEL W ELL CASING DIA: <br /> [] EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: <br /> []VAPOR `[]MUD ROTARY DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE/OZONEx PUSH POINT(GP r CPT)GROUT SEAL PUMPED: []Yes j No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [X]SOIL BORING [] AND AUGE GROUT SPECIFICATIONS <br /> []OTHER: []OTHER APPROX.BORING DEPTH 5 []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Soil borines will be installed up to 5.5 feet Nes using a direct-push method Borings will be backfilled with neat cement <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 /> Signed x �(/1/t/� v- t Title/Company_Staff Engineer/Geomatrix Consultants <br /> Print Name Mi-ae Jeon Date 8/7/03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /d GU • �'j]//� l(U-�) <br /> WORK PLAN DATED: - / <br /> Application Accepted By Date IssuedU Z grea�FA <br /> Grout Inspection By Date Final Inspection By z -17715e <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/SERVICE REQUEST# INVOICE <br /> dl o t < //o ? > <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />