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7 <br /> I <br /> SAN JOAQUIN COUNTY <br /> N' ? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> t 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:Www.sjyov.org/ehd <br /> UNIT IV <br /> . �,F OKw• <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herein k6de'ko 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 Devglopment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessor's <br /> L' <br /> -4Ve+ Location 1550 Industrial Drive Cross Street S Airport Way City Stockton Zip 95206 Parcel <br /> Property <br /> I Owner Metalsa Address 1550 Industrial Drive City Stockton Zip 95206 Phone#209-983-6100 <br /> C-67 Contractor Vironex Address 5292 Pacheco Blvd City Pacheco Zip 94553 Lid# 705927 Phone <br /> Consuttant/Sub Cntr ENVIRON Address 707 Wilshire Blvd,Ste 4950 City. Las Angeles Uc# Phone 213-943-6300 <br /> 1 GIS Coordinates:X 1121015'16.14 W Y 37054'36.87 N ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAPID-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING#8 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> []"OTHER GROUT SPECIFICATIONS <br /> j ❑EXPLOSIVES DETONATING CARD <br /> lCOMMENTS: Borings will be backfilled with a portland cement slurry(5 to 1 ratio)upon sample completion. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.25' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:NA <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE IN PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NA <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED OfYES.1131 spacific dons in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a d all appli Califo nia Laws. <br /> Signed Title/Company Associate/ENVIRON International Corp. <br /> Print Na a Alma Queza a Date June 30,2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l SSD —L.�c>°u j L (�—�� a�I•SQ <br /> WORK PLAN DATED: 1 <br /> APPLICATION ACCE ED BY / DATE ISSUE ? t U AREA <br /> GROUT INSPECTION BY i FINAL INSPECTION BY r D DATE <br /> DESTRUCTION INSPECTION BYCC�c nn DATE <br /> COMMENTS/CONDITIONS: GTrt. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC -WAlvcn C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT APP <br /> �'3 V-r-- 34�� <br />