Laserfiche WebLink
Fri" � �� <br /> „IL� <br /> COPY <br /> WELL ER{:MIT APPLfCATIQN FORM SITE <br /> SAN JOAQUIN COUNTY <br /> MITIGATION <br />` ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UI'^NIT IV <br /> 304 E. Weber,-Third Floor, Stockton, CA., 95202 <br /> { k;r (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRi*5 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 g <br /> Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San JoaquirCounty Environmental Health Department. <br /> 'Ilk As'sessor's <br /> WELL Location 2360 East Street Cross Street G'rantllne Blvd City Tracy Zip 95376 Parcel#- 233460-01 <br /> PROPERTYOwner John Pestana f2TIP Trust Address P:O.Box 672 City Manteca Zip 95336 Phone# 209-239-5033 <br /> C-57 Contractor Fisch Environmental Address .;.399 Shari's Place City Vaile5pringsZip 95252 Lic#683865 Phone# 209-772-3570 <br /> Consultant/Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X 37'45' 14.5" ,Y -121°25'11.5" ;Township 2S Range 5E Section 21A i <br /> WORK TO BE PERFORMED: � I E <br /> Tq NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) j []DESTRUCTIQN(choose type below) F <br /> 03 [X]SOIL BORING# CPT1 andidPT2 b CPT SB12D and SB13D by direct push ©OVER-BORE I <br /> Q WELL# p PRESSURE GROUT <br /> "Other: of, 'lit Grout Specifications: <br /> COMMENTS: <br /> �- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING []HOLLOW STEM DIA;OiF,BOREHOLE 1.75-2" MULTIPLE CASINGS?0 YES []NO WELUCASING DIA: <br /> a EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC' aOTHER: <br /> a VAPOR a MUD ROTARY DEPTH bF GROUTSEAL full depth 1I TREMIE TYPE TO BE USED: ©AUGERS a HOSE <br /> Q AIR SPARGE [X]PUSH POINT GROUTkSEAL PUMPED: [X]Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Vq SOIL BORING ©HAND AUGER GROUT-SPECIFICATIONSmeat cement grout orbentonite <br /> Q OTHER a OTHER APPROX.BORING DEPTH 35-40 feet, p BOLTED TRAFFIC BOX or p STOVE PIPE ? <br /> CONDUCTOR CASING PROPOSED? IM (if YES, list specifications here): <br /> "COMMENTS _ -. I {` ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORI 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 ces, ul s and Regulations,a'nd'all applicable California�State Laws. <br /> Signed x �� Title/Company CA R.G.6795,Ground Zero Analysis!I Inc. <br /> Print Name John P. Lane 11 li E[ Date May 13,200 5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> �I <br /> WORK PLAN DATED: S�l2 ro I <br /> Application Accepted By 3, Date Issue d "o i Area! <br /> Grout Inspection By Date -7—Lq I Final InspZection By ate_7-2_1­0.-O I <br /> Destruction Inspection By <br /> COMMENTS!CONDITIONS <br /> [ZACCOUNTING ONLY: AID# Ir <br /> S FEE INFO AMOUNTREMITTED CHECK# RECD BY DATEE� PERMIT/SERVICE REQUEST# INVOICE <br /> sS-te DD ?- ZWC -WAIVER C-57 Letter ''v'f Authorization to sign permitEncroachment doe`�✓/f 1/25T02 I <br />