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PAYMENT <br /> EDSAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT SEP -3 2009 SITE <br /> 600 East Main Street, Stockton, CA 95202-3029SAN Jo ITIGATION <br /> 1 2 09 Telephone: (209)468-3449 Fax:(209)468-3433 Web:WWW.S o ECONTAL UNIT IV <br /> e�xN EALTH DEPARTMENT <br /> ENVIRO ENS HEALTH <br /> ICES WELL PERMIT APPLICATION <br /> pERNiiTIS�RV <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 Forward Landfill Cross Street South Austin Road City Manteca Zip 95202 Parcel# 201-060-002 <br /> Property <br /> Owner Allied Waste Industries Address 6800 Koll Center Parkway City Pleasanton Zip 94566 Phone# (925)201-5823 <br /> C-57 Contractor Test America Drilling Address 1016 E. Katella Avenue City Anaheim Lic# 819548 Phone (714)939-6850 <br /> ConsultanVSub Cntr Address City Lic# Phone <br /> GIS Coordinates:X 37.87417 'Y -121.18828 Township LIS. Range R.7E. Section SEWC,3 <br /> "RK TO BE PERFORMED: <br /> pJ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# rP-96_rP-77 ❑PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS:Title 27 Landfill Gas Monitoring Probes <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,( <br /> MONITORING (HOLLOW STEM DIA.OF BOREHOLE 8"-10„ El MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCH 80 TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED,6AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes dNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Hydrated Bentonite <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 36 Feet Max. BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Please Refer to the Attached Approved Workplan for further Program Details. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 8 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepare application and that the work will be done i accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ble C nig Laws. <br /> Signed Title/Company Project Manager/BAS&Associates, Inc. <br /> Print Name Rodolfo Coto Date 2(f® <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY.`'�L C��2J�.r—. —s FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 414 w1y 1 � " 3 0 SR#0059 <br /> 657 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />