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ORIGNAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 7 ZG0? SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> NViIC �(H 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 VV D -K <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 Bridgeport Trails Development Unit 5 Cross Street Fresno Ave. City Stockton p_15206 Parcel# Various <br /> PROPERTY Owner Crosswinds of California Address 41 Yokur Ave. #107 City Stockton Zip 95206 Phone# 209-938-0890 <br /> C-57 Contractor Spectrum Exploration Address 2365 Wigwam Dr. City Stockton Zip 95207 Lic# 512268 Phone# 209-465-8712 <br /> Consultant/Sub Cntr Geomatrix Consultants Address 2444 Main St.Suit 215 City Fresno Lic# Eff 26 C Phone# 559-264-2535 <br /> GIS Coordinates:X -648299E ,Y -4199296N ,Township T1N Range R6E Section Unknown <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER-) DESTRUCTION a below) <br /> _0 SOIL BORING# x] VER-BORE <br /> D WELL# URE GROUT <br /> 'Other: rout Specifications: <br /> COMMENTS A /LO 'TLt/ r Cr d G f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [x]MONITORING [x]HOLLOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS?DYES [x]NO WELL CASING DIA:_ <br /> H EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: a STEEL [x]PVC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -0 to 10 feet TREMIE TYPE TO BE USED: [x]AUGERS 0 HOSE <br /> H AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [x]Yes H No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: o OTHER APPROX.BORING DEPTH -28 feet a BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: Seven wells are been destroyed per RWQCB approval(see may). Three wells are being retrofitted Into permanent monitoring wells. <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, Rules <br /> and Regulations, and all applicable California State Laws. <br /> Signed xC ff7 Title/Company <br /> Print Name /C nL <br /> / -cQ �• C�P2h Date <br /> /DEPARTMENT/U�S�E�,ON ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1?e e- C � � � � <br /> WORK PLAN DATED: Z '2-6 "0Z py' <br /> Application Accepted By �/ Date Issued tel" Area Q�6 / <br /> Grout Inspection By // Date_ Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2-- <br /> C-57 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />