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WEL'�`PERMIT APPLICATION 4M <br /> n ° SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> �[�W ONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 34 �:Weber, Third Floor, Stockton, CA., 95202 <br /> 11EALTH (209) 468-3449 <br /> QEFUNDABLE 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 JoaquirCounty 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 /> PROPERTYOwner Cal Trans Address city Zip Phone# <br /> C-57 Contractor_V&W Drilling Address 100 S"Street City Isleton Zip 95641 Lic# 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 /> ONEW WELL 1 BORING(CPT,GEOPROSE, HYDROPUNCH,HAND-AUGERPTHER') [X]DESTRUCTION(choose type below) <br /> 0 SOIL BORING# VER-BORE <br /> 0 WELL# <br /> "Other: Grout Specifications: Neat cement grout of well MW2-r'k)ALAA. mils <br /> COMMENTS: 921k 011rcel W; k;r l e-r 4 verl"6,+ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Cacti' <br /> II MONITORING []HOLLOW STEM DIA. OFSOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS d HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEP H IS 0') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_O OTHER APPROX. BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> 'COMMENTS: Pressure grout of well MW2 overdrill upper three feet <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORIENCROACHMENT PE MIT <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED IN IONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordant t oaquin <br /> County Ordinanc p, �andlations, and all applicable California State Laws. <br /> T Signed x _ _ Title/Company RG.6795 Ground Zeroniv,,' Inc <br /> Print Name John P. Lane Date <br /> DEPARTMENT USE ONLY , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By "V Date Issued "� Area <br /> Grout Inspection By IV <br /> Date 1-1 x.Vto< Final Inspection By Dated <br /> Destruction Inspection By Date bx pts—" <br /> COMMENTS 1 CONDITIONa V V VLe 40#�ftj <br /> ACCOUNTING ONLY: 1- mettc Way r ulY t - mjPc W i-e a r� :S �/Mt f W; <br /> �e 1r a s w <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D DAT PERMIT/SERVICE REQUEST# INVOICE <br /> SO 0 230 3 n <br /> C-57 WC -WAIVER C-57 Letter of Auth iza o sin r <br /> rmit Encroachment dot 1/25/02 <br />