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a�4''ty SAN JOAQUIN COUNTY <br /> �.•.��'•.oma <br /> ` z ENVIRONMENTAL HEALTH DEPARTMENT <br /> •-� SITE <br /> { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sogov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 9999 S.Austin Rd. Cross Street Arch Road City Manteca Zip 95336 Parcel# 181-150-08 <br /> ' Property <br /> Owner Fomerd,Inc Address 1145 W.Charter Way City Stockton Zip gszos 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:XA36Q74&-,'- Township 1N Range 7E Section 34 <br /> WORK TO BE PERFORMED: <br /> ' x❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑x WELL# AMW-31S ❑PRESSURE GROUT <br /> ❑*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 /> ❑X 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 I]PVC ❑ OTHER <br /> ❑VAPOR @ MUD ROTARY DEPTH OF GROUT SEAL 0-e JIL TREMIE TYPE TO BE USED❑AUGERS❑x HOSE <br /> ❑AIR SPARGE/OZONE EI PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 6 x 94#Portland cement+max.5%bentonite+100 gal water <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _LV+99r I ❑BOLTED TRAFFIC BOX OR :❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (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 applicatiojLand that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Staff Biologist /Herst&Associates,Inc. r' <br /> Print Name Erin Fanning Date <br /> DEPARTMENT USE ONLY <br /> t SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> ' o <br /> GROUT INSPECTION BY a' 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 /> 1I S R# <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />