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WELPPER6VIIT APPLICATION ARM SITE <br /> MITIGATION <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 <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 /> Assessis <br /> WELL LocationROBERTS ISLAND—HOUSE ROAD Cross Street HOLT ROAD city STOCKTON Zip95203 Parcel#�31-230-02 <br /> PROPERTY Owner STOCKTON PORT DISTRICXddress2201 W WASHINGTON CitySTOCKTON Zip95203 phone#209-946-0246 <br /> C-57 Contractor SPECTRUM EXPLORATLWklress2365 WIG64AM DR. City STOCKTONkii;95205 Lic#512268Phonet2O9-465-8712 <br /> Consultant/Sub Cntr GEOMATRIX CONSULTAWEEress 2444 MAIN ST. #21fxy FRESNO Lic# Phone#559-264-2535 <br /> GIS Coordinates:X 121.3888 W Y--37.9722 N Township T 2 N Range R 5 E Section <br /> WORK TO BE PERFORMED: <br /> X�]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> XI,XSOIL BORING# 5 0 OVER-BORE <br /> p WELL# p PRESSURE GROUT <br /> *Other:HOLLOW STEM AUGER Grout Specifications: CEMENT BENTONITE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 6 _MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC BOTHER: <br /> I]VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> B AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NEAT CEMENT--BENTONITE <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 10 f't B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: SOIL BORINGS WILL BE GROUTED VIITH NEAT CEMENT <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 c5i that I have ared this application and that the work will be done in accordance with San Joaquin <br /> County O I ce es a Regulations, and all applicable California State aws. <br /> Signed x �''� Title/Company G <br /> Print Name i� OSS S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By M-1 Date Issued D�/�C�2— Area FSA <br /> Grout Inspection By Date11 Rjj� inal Inspection By Date <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 <br /> to ale- L6 t v t7Z- SR# 603156-7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />