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• 0 01 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> MAR 2 7 202 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRO'\w1EiJT f!EALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERy91T/SER<V,ES (209) 468-3449 M X15 B <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 W.Charter Way Cross Street Fresno Ave. City Stockton Zip 95206 Parcel# 163-020-17 <br /> PROPERTY Owner Miller Springs Remed.Mat Inc. Address 2480 Fortune Drive,Suite 300 City Lexington,Kv Zip 40509 Phone# 859-543-2160 <br /> C-57 Contractor. Spectrum Exploration Address 2365 Wigwam Dr. CityStockton Zip 95207 Lie# 512268 Phone# 209-465-8712 <br /> Consultant I Sub Cntr Geomatrix Consultants Address 2444 Main St.Suit 215 CityFresno Lic# F9760 Phone# 559-264-2535 <br /> GIS Coordinates:X -648299E 1Y -4199296N ,Township Tl N Range R6E Section Unknown <br /> WORK TO BE PERFORMED: <br /> [x]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> _0 SOIL BORING#--- a OVER-BORE <br /> (x]WELL MW-5B 0 PRESSURE GROUT <br /> 'Other: � Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [x]MONITORING [x]HOLLOW STEM DIA.OF BOREHOLE 12" MULTIPLE CASINGS?0 YES [x]NO WELL CASING DIA: 6- <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL [x]PVC p OTHER: <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL -0 to 10 feet TREMIE TYPE TO BE USED: [x]AUGERS [I HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [x]Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH -28 feet 0 BOLTED TRAFFIC BOX or [x]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> 'COMMENTS: Well is a replacement for MW-5a,destroyed during soil remediation. <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 Ordinances�-R leA�s�gaand Regulations, and all applicable Californian State Laws.Q <br /> Signed x �' `- Title/Company " rA e-,Pr�S� <br /> Print Name rtJ Ct, -'(% Date <br /> DEPARTMENT USE ONLY <br /> NM <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l!d / Z • c Lce, Gni / �/II "OP <br /> WORK PLAN DATED: 2,7' N <br /> Application Accepted By ? Date Issued �t� Z� Area <br /> Grout Inspection By r Date Final Inspection B._ - 'F Mfst+ r DDate7' Z14'4 Z <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �nrx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D BY DAT5 PERMIT/SERVICE REQUEST# INVOICE <br /> Z o l !0 2q 27 s ODZ 3t 6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />