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WELL PERMIT APPLICATION ARM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 8751 E. Highway 12 Cross Street Bruelle Avecity Victor zip 95253 Parcel# 051-03-63 <br /> PROPERTY owner Dole Food Company Address 10900 Wilshire Blvdeit L. Angeletip 90024 Phone$l0-824-1023 <br /> C-57 ContractorSpectrUm ExploratiAMra;nc.2365 Wigwam Dr. cit tockton z;P CAC c#5121,?,-hon&209-465-8712 <br /> c.ZiS <br /> Consultant/Sub Contractor Geomatrix ConsultM"% Inc. 2444 Main Sb-y Fresno LicX501450Phone#559-264-2535 <br /> GIS Coordinates:X ,Y ,Township 3North Range 7 EastSection 4 <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> ','SOIL BORING#PB-1 through PB-6, BGB-1 r BGB-2 0 OVER-BORE <br /> []WELL# []PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING *HOLLOW STEM DIA.OF BOREHOLE R MULTIPLE CASINGS?flYES []NO W ELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: <br /> — <br /> I]VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> WOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER:_0 OTHER APPROX.BORING DEPTHO-10 0-30 rbgff BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? no (if YES,list specifications here): <br /> "COMMENTS: <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 J,1f e� pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan �, ulee eg ns all applicable California State Laws. <br /> Signed x Title/Company POS-+A�.�2� <br /> Print Name �- Date 7 rb <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 5 1 - �� ( Z VL_C`zf`°'^� fsoc,"Q ' <br /> WORK PLAN DATED: 3 <br /> Application Accepted By "_>K 1_1C Date Issued l a �� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> P-9n 'i�R. 00 03ZZ-4 -1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />