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SAN JOAQUIN COUNTY <br /> ` 'ft ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> E�� 00 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> e7e (209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> t U� 15 2011 WELL PERMIT APPLICATION <br /> EWp0NMENTALH LOU-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is heret?68WTd,%fi1%GW 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 9999 S.Austin Rd. Cross Street Arch Road City Manteca Zip 95336 Parcel# 181-150-08 <br /> Property <br /> Owner Fon­,d,Inc. Address 1145 W.Charter Way City Stockton Zip 95206 Phone# 800-204-4242 <br /> 209-465-8712 <br /> C-57 Contractor Precision Sampling,Inc. Address 2365 Wigwam Drive City Stockton Zip 95213 LIC# 636387 Phone <br /> ' Consultant/Sub Cntr Herst&Associates,Inc. Address 4631 North St.Peters Parkway City Saint Charles LIC# Phone 636-939-9111 <br /> GIS Coordinates:X-6&6W*@.6 Y 6' Township 1N Range 7E Section 34 <br /> WORK TO BE PERFORMED: <br /> ' xE NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> Ex WELL# AMW-31 ❑PRESSURE GROUT <br /> E"OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:Replacement monitoring well AMW-26R will replace AMW-26 which is currently located in the construction zone of the proposed California Health Care Facility. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> EX MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 inch <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Sch 80 TYPE OF CASING:❑STEEL ❑x PVC ❑ OTHER <br /> ' ❑VAPOR ❑Q MUD ROTARY DEPTH OF GROUT SEAL 0- 2 n j4LTREMIE TYPE TO BE USED❑AUGERS El HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 6 x 94#Portland cement+max.1%bentonite+100 gal water <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1,Wfeet ❑BOLTED TRAFFIC BOX OR [j]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED If (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> ' I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Cali rnia Laws. <br /> Signed Title/Company Staff Biologist /Herst&Associates,Inc. <br /> ' Print Name Erin Fanning Date - �1 <br /> DEPARTMENT USE ONLY PAYMENT <br /> RECEIVED <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: ►rnY 7 2011 <br /> cutI <br /> WORK PLAN DATED: I <br /> IN COUNTY <br /> APPLICATION ACCEPTED BY DATE ISSUED }gNMFPMNTAENT <br /> GROUT INSPECTION BY G FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY i DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# f <br /> PE CODES JFEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> ' 7/ 02 g" -Zltl- << 17 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E CROACHMENT DOC <br /> 1 EHD 29-01 10/28/09 WELL PERMIT APP <br />