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FILE COPY <br /> [RECENED WELL PERMIT APPLICATION FORM SITE <br /> NOV 0 8 2002 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <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 5E Section 4 <br /> WORK TO BE PERFORMED: <br /> [x] NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [x] DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> [X]WELL#TW-1,TW-2,TW-3,TW-4 [X]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 Ord++inances�,}Rules and Regulations, and all applicable California State Laws. L <br /> Signed x (lc1td 7.� JCA ` Title/Company 5td(f G �UR!5 rpa/ct11 cV� <br /> Print Name Crar4 -Tr ba th Date l0/3"Lo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 61 <br /> Application Accepted By Date Issued �/ �� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z 0 � V� o .5&- 'V6 //- g SR 318 <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit V Encroachment doc_ 9/30/02 <br />