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m. <br /> WELUPERMIT APPLICATION-FYC kM SITE <br /> SAN JOAQUIN COUNTY UNIT IVTfON <br /> JAN 0 5 7.Q 45 ENVIRONMENTAL HEALTH DEPARTMENT (EHD)'' <br /> SAN JOAQUIN COUNTY304 E. Weber, Third Floor, Stockton,:-CA., 95202 <br /> ENVIRONMENTAL HEALTH.DEPT. (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 8200 N.Hwy.99 Cross Street Foppiano City Stockton Zip 95212 Parcel# 085-310-11 <br /> PROPERTY Owner Ray_Ba9lietto/Frank Rauzi Address 301 S.Aurora St. City_Stockton_Zip 95203 Phone# 209-466-0433 <br /> C-57 Contractor V&W Drilling Address 100 5th Street City Isleton Zip 95641 Lie# 720904 Phone# 916-777-4100 <br /> Consultant/Sub Contractor Ground Zero Analysis Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X Y Township 2N Range 7E Section 18E <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> D SOIL BORING# D OVER-BORE <br /> [x]WELL# VW2 D PRESSURE GROUT <br /> `Other: Grout Specifications; I <br /> COMMENTS: I, <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> D MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE 10" MULTIPLE CASINGS?D YES [x]NO WELL CASING DIA: 4" <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS:Sch 40_TYPE OF CASING: D STEEL [X]PVC 0 OTHER: <br /> [x]VAPOR VW2 D MUD ROTARY DEPTH OF GROUT SEAL 20'TREMIE TYPE TO BE USED: [x]AUGERS D HOSE l <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yes [x]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat Cement Grout <br /> D OTHER:_a OTHER APPROX.BORING DEPTH 47' D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): <br /> 'COMMENTS: <br /> .a <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 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. <br /> Signed x 144- Title/Company RG.6795, GroundZeroAnalysis,Inc. <br /> Print Name John P.Lane Date_ Q( !Ol/,O -S7 <br /> _-DEPARTMENT-USE-ONLY fl <br /> I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J <br /> WORK PLAN DATED: <br /> Application Accepted By �' Date Issued } v Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY PERMIT!SERVICE REQUEST# INVOICE <br /> 00 a n 1 <br /> — <br /> C-5T- WC -WAIVER C-57 Letter of Autho i it Encroachment doc 1/25/02 <br />