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WELL46MIT APPLICATION AM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 Averity Victor zip 95253 Parcel# 051-03-63 <br /> PROPERTY Owner Dole Food Company Address 10900 Wilshire Blvdait LosAngele%p 90024 PhoneM-824-1023 <br /> C-57ContractorSpectrum ExploratiAMrAgc.2365 Wigwam Dr. Ci tocktonzip CA C�`�-51A;aMon9#209-465-8712 <br /> StG.24 <br /> Consultant/Sub Contractor Geomatrix ConsultM"g Inc. 2444 Main S&y Fresno UcA501450 phone#559-264-2535 <br /> GIS Coordinates:X ,Y ,Township 3 North Range 7 East Section 4 <br /> WORK TO BE PERFORMED: <br /> I]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> )'SOIL BORING#PB-1 through PB-6, BGB-1, BGB-2 p OVER-BORE <br /> I]WELL If 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1]MONITORING WHOLLOW STEM DIA.OF BOREHOLE H MULTIPLE CASINGS?DYES ONO WELL CASING DIA: <br /> 1]EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL I]PVC (1 OTHER: <br /> D VAPOR I]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS I]HOSE <br /> I]AIR SPARGE I]PUSH POINT GROUT SEAL PUMPED: I]Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 7WSOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: I]OTHER APPROX.BORING DEPTHO-10. 0-301bgS BOLTED TRAFFIC BOX or p 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 certifythat J,�( pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinann , ule ns all applicable California State Laws. / <br /> Signed r r l <br /> Title/CompanyS eDP-4 Ar-R C <br /> Print Name Date -r/14,4 r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S 1 - 7 ( Z `�61^O ` ��r^ `� rte• <br /> WORK PLAN DATED: 3 i f -7 1 l6I <br /> Application Accepted By Lk lyt�C� Date Issued 7'11 b C>/ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# rnru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �l9 D <br /> '81- 00 03ZZ41%10) SR# �,6FS0 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />