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�EC Fc � ', c D WELL PERMIT APPLICATION FC, M SITE <br /> ��� ," MITIGATION <br /> " AUG 1 8 2004 SAN JOAQUIN COUNTY - UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENViR0N1i101 HEALP;04 E. Weber, Third Floor, Stockton, CA', 95202 <br /> PERMMSERVICES (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 /> Assessor's <br /> WELL Location 601 w.lockeford Street Cross Street California City Lodi Zip 95240 Parcel# Q�� <br /> PROPERTY Owner Larry Howen Address P.O.Box 203 City Lockeford Zip95237 Phone# 209-727-5527 <br /> C-57 Contractor Fisch Environmental Address 399 Shari's Place CityVall�gsZip 95252 Lic# 683865Phone#249-772 3570 <br /> l <br /> Consultant!Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-8389888 . <br /> w <br /> GIs Coordinates:X 121°16.8008'W Y 38°08.3034'N ,Township 2S Rance 9E Section 23 <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL I BORING(CPT, OPROBE, DROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> # SB1-SB6 0 OVER-BORE <br /> [X]WELL# B PRESSURE GROUT <br /> *Other., Grout Specifications: " Neat cemendbentonite rout <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE a CONSTRUCTION SPECIFICATIONS <br /> MONITORING B HOLLOW STEM DEA.OF BOREHOLE2' MULTIPLE CASINGS?B YES jX]NO WELL CASING DIA: NA <br /> B EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF;CASING 0 STEEL 0 PVC BOTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL. 10-20ft TREMIE TYPE TO BE USED: B AUGERS [x]HOSEPIPE <br /> B AIR SPARGE [X]PUSH POINT GROUT SEAL PUMPED: U Yes [X]No (MOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> [X]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat cementlbentonite grout <br /> B OTHER: 0 OTHER APPROX.BORING DEPTH10-20 ft. B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: i. <br /> 'i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT]V 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 County <br /> Ordinances, Rules and R gulations, and all applicable California State Laws. <br /> Signed x _Title/Company CA Registered Geolo st 6795 Ground Zero Analysis,Inc. <br /> Print Name 'John P.Lane I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d <br /> WORK PLAN DATED: <br /> e <br /> Application Accepted By <br /> Date Issued i O Area 1� <br /> Grout Inspection By o+n�� Date O� Final Inspection By Date 0 <br /> a <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: 1 <br /> ACCOUNTING ONLY: AID# FAG#FEEINFO AMOUNT R7EMITTEDPE CODES FEE INFO AMOUNT REMITTED CHECK# REC'❑BY T <br /> E PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> j <br /> ' i i <br />