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WELL ERMIT APPLICATION FYRM SITE <br /> MITIGATION t <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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 JoaquirCounty Environmental Health Department. <br /> Assessor's <br /> WELL Location 10842 S. Harlan Roagl Cross Street Roth Road City French Camp Zip Parcel# 1933028 <br /> PROPERTY Owner Beneto Inc. Address P.O Box 980220 City West Sacramento Zip 95798 Phone# 916-677-0819 <br /> C-57 Contractor Spectrum Exploration Address 2365 Wigwam Drive City Stockton Zip 95205 Lic# 512268 Phone# 209-465-8712 <br /> CohsultantlSub Contractor Lee&Pierce. Inc- Address 546 Abbott Street Suite 20 City Salinas LickPhone# 831-758-0996 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) I]DESTRUCTION(choose type below) <br /> pSOIL BORING# SB4 drilled to 75 ft bvCPT _- _ ---=�---f--- -- 0 OVER-BORE.,--.- ---.,- <br /> r_ [X]WELL# UW-1 MW2 MW3 installed to 30 It by Hollow Stem Auger - PRESSURE GROUT <br /> `Other: Grout Specifications: Neat cement Grout <br /> COMMENTS:Workplan prepared by CA Geophysical Group(03/22/06)on file at EHD. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE 8 1/2" MULTIPLE CASINGS7Q YES [X]NO WELL CASING DIA: 2" <br /> o EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: n STEEL [X]PVC OOTHER: <br /> n VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 11 ft TREMIE TYPE TO BE USED: [X]AUGERS 0 HOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: 0 Yes [X]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS Neat cement grout over hydrated bentonite pellets I <br /> n OTHER 0 OTHER APPROX. BORING DEPTH 30 It [X]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): - <br /> *COMMENTS: Grout seal pumped for boring(up to 75 ft) but free fall for wells(less than three feet due to shallow aroundwaterl <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 /> r <br /> County Ordina ces, ules anre�tions,and all applicable California State Laws. <br /> Signed xTitle/Company CA Registered Geolo st 6795 Lee&PierceInc. 1 <br /> Print Name John P. Lane) Date 6 31 <br /> _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '(A <br /> j WORK PLAN DATED: ,In w W -2- -2 <br /> Z / O� [ I]eo PG,�rrr <br /> li Application Accepted By Date Issued (?/3A(, Area <br /> 11 Grout Inspection By Date 9� D� Final Inspection By DateT�� <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/SERVICE REQUEST# INVOICE 1 <br /> f iso. sg <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 4 <br />