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Rf1 A <br /> nWELL PERMIT APPLICATION FORM <br /> SITE <br /> NOV 0 8 2002 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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 /> Assessors <br /> WELL Location: 400 West Gandy Dancer Drive, (see map Cross Street: S.Tracy Blvd City: Tracy Zip:95377 Parcel# 248-030-02 <br /> PROPERTY Owner: Dow Chemical Address: 400 West Gandy Dancer Drive City: Tracy Zip:95377 Phone# 209-836-4440 <br /> C-57 Contractor: Gregg Drilling Address: 950 Howe City: Martinez Zip:94553 Lic# Phone# 925-313-5800 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township 35 Range SE Section 4 <br /> WORK TO BE PERFORMED: <br /> [x] NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [. ] DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> [X]WELL#TW-1,TW-2,TW-3,TW-4 U I PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2"PVC <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2" TYPE OF CASING: 0 STEEL [X]PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 60' TREMIE TYPE TO BE USED: [X]AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: [X]Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 75' [X]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED: No (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 and Regulations, and all applicable California State Laws. 11 <br /> Signed x �.I�t. 7�A ` Title/Company 5?d(f 4eolooi5f �UR5 6 rpo/cL7 V-) <br /> Print Name 0, ' M 6,0 Date (o�TOz <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Oc) <br /> WORK PLAN DATED: — C)2-- <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By J6b a ate /-4 —0-3 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> _N, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 0� V� 03 ` g SR �18� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit . Encroachment doc 9/30/02 <br />