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o.¢` `'!y•.c • SAN JOA UIN COUNTY • <br /> Q <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �%FCR <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 Fomarn,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 Llc# 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 6359131.3 Y 2145750.3 Township 1N Range 7E Section 34 <br /> WORK TO BE PERFORMED: <br /> ' x❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> x❑WELL# AMW-32S ❑PRESSURE GROUT <br /> ❑ <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 /> ❑% 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 L TYPE OF CASING:❑STEEL []PVC ❑ OTHER <br /> [I6�9 VAPOR El MUD ROTARY DEPTH OF GROUT SEAL ' 4/y 4r TREMIE TYPE TO BE USED❑AUGERS❑x HOSE <br /> ❑AIR SPARGE/OZONE ❑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 90 Portland cement+max.5%bentonite+100 gal water <br /> t ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 125 feet ❑BOLTED TRAFFIC BOX OR ❑'< STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> t 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 California Laws. <br /> Signed Title/Company Staff Biologist/Herst&Associates,Inc. / <br /> Print Name Erin Fanning Date <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 I L 124 11 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 /> ') Ivj SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> tEHD 29-01 10/28/09 WELL PERMIT APP <br />