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SAN JOAQUIN COUNTY <br />jum i g 2009 ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Vfi;�'f`v�ll hteC f6": (209) 468-3449 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />WELL PERMIT APPLICATION <br />JUN 3 0 2009 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma61WIhL7 ENVIRON ON an <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 South Austin Rd Cross Street Newcastle Road City Manteca Zip 95336 Parcel # 181-15-8 <br />Property <br />owner Forward, Inc. Address 9999 South Austin Road City Manteca zip 95336 Phone # 209-982-4298 <br />C-57 Contractor Precision Sampling, Inc. Address 2365 Wigwam Drive City Stockton Lic# 636387 Phone 209-465-8712 <br />Consultant/Sub Cntr Herst & Associates Address4630 S. Hwy 94-N. Outer Road City St. Charles, MO Lic # <br />GIS Coordinates: X 6359668 Y 2146422 , Township 1 North Range 7 East <br />WORK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />❑ SOIL BORING# <br />[id WELL # AMW-21 S <br />❑ *OTHER <br />rKi]TIIF, IAIN, I <br />TYPE OF WELL <br />❑X MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />INSTALLATION TYPE <br />❑ HOLLOW STEM <br />❑ AIR HAMMER/DRIVEN <br />Phone 636-939-9111 <br />Section 34 <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 Inch <br />CASING THICKNESS SCh 80 TYPE OF CASING: ❑ STEEL Rl PVC ❑ OTHER <br />R MUD ROTARY DEPTH OF GROUT SEAL 0-85 ft TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ® Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />❑ SOIL BORING ❑ HAND AUGER <br />❑ OTHER: <br />COMMENTS: <br />❑ OTHER: <br />GROUT SPECIFICATIONS 4 x 94# Portland cement + max. 5% bentonite + 100 gal water <br />APPROX. BORING DEPTH 116 feet ❑ BOLTED TRAFFIC BOX OR ® STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I a eparejAhisapplication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and a I le a fornia aws. <br />SignedTitle/Company Manager -Remedial Services/Herst & cAssociates, Inc. <br />Print Name William J.Jbernathv Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY `' �f C`� DATE ISSUED If, AREA Z <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTIONWy1_4L <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />1 <br />PERMIT/SERVICE # <br />INVOICE <br />_;34 n <br />SR# <br />C-57 - WC <br />EHD 2"1 11/5/07 (WEB) <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN'PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />