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02/11/2003 15:12 FAX 209 948069 ` . rIt {,� pY <br /> 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 /> (209) 468-3449 - <br /> L <br /> NON-REFUN ABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED licetion is made in compliance with'San ` <br /> Application I$hereby made to San Joaquin County for a permit to construct and/or install the work described. This app <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentAssessors <br /> WELLLocation_110FIIhertStreet Cross Street..Myrtle Street City_SlacktenZip_95202_Parce9)_157-02-0OL- <br /> PROPERTY Owner Del Monte Plant 033 Address 27`16 E.Miner Ave._City_Stockton_Zlp_95200_Phone#_925-944-7275 tiLk <br /> C-57 Contraotor_Spectrum Address_2365 Wigwam Drive_City_Steekton_Zlp_95205_Lio#_512268_Phone#_209-4656712_ <br /> M <br /> ConsulfaI Sub Cntr_Kleinfelder,InC._Addre65_2625 E-Myrtle St._City_StoCktdnPhone$_208-846-1345 <br /> _UC# _ <br /> GIS Coordinates:X <br /> Y- JTownship_1N Range_6E <br /> Seclion_1 <br /> WORK TO BE PERFORMED: DESTRUCTION (d+oose type below) <br /> IXI NEW WELL I BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) D D OVER-BORE, DIAMETER_ <br /> D SOIL BORING# OPRESSURE GROUT <br /> PCI WELL# A10 ASCO 14Z— VES rb eo(LIW S) GROUTSPECIFICATIONS ill <br /> COMMENTShBAS2 h5 r ,dD m.a..EA PFi O�-P '� of 9or I'ao' <br /> VE 7- - �I Lr.C, <br /> + s Of r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING IXI HOLLOW STEM DIA.OF BOREHOLE_8" IXI MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_t 7 <br /> D EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS_Sch.4D_TYPE OF CASING: D STEEL (XI PVC D OTHER: <br /> Pq VAPOR D MUD ROTARY DEPTH OF GROAT SEAL_14',66',136'_TREMIE TYPE TO BE USED: pq AUGERS D HOSE <br /> Dq AIR SPARGE!OZONE D PUSH POINT(GP'or CPT) GROUT SEAL PUMPED: D9 Yes D No <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS_Neat Cement <br /> D OTHER;_11 OTHER - APPROX.BORING DEPTH_140' IXI BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—No (If yES,list specifications In commentsection) r" <br /> COMMENTS: S7- ASS- i+-�S+ r> a� 11r PJL KI 'n MS r+F 9cr I14 J' �E1-J r,5'- r,.ky wE4 w+l i' PJ C.03S r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> i <br /> t I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ord-, a s,Rules and lations, and all applicable California State Laws. <br /> Signed z TlflefCompany STAFF&-JCIA r 1 6F-1L lr- . ..s f,6.ZE4 <br /> Print Name J $ 3 Date 2� <br /> 1%�o - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: I D ril b/14 S-77jfh� <br /> WORK PLAN DATED":�-y � � q G q <br /> Application Accepted By 1 r L �'a+s Data Issuod Oth/l Q 3 - Area / <br /> Grout Inspection By Date Final Inspection By T Date - <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: - <br /> ACCOUNTING ONLY: AID# FAC# - - - - <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK"* REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE- <br /> G a SR# 3a?3 <br /> C-57 WC, r WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc— 9/30/02 <br />