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PAYMENT <br />P"' ` ` SAN JOAQUIN COUNTY RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT SEP -3 2009 SITE <br />� �I <br />600 East Main Street, Stockton, CA 95202-3029SAN Jo LITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s o N� COU UNIT IV <br />www.. <br />DEPARTMENT <br />01ROtWENRVICESH WELL PERMIT APPLICATION <br />pERMITISE <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 />Consultant/Sub Cntr <br />GIS Coordinates: X 37.87417 , Y -121.18828 , Township <br />WQRK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />SOIL BORING# <br />WELL # CP -9R C;P-97 <br />*OTHER <br />COMMENTS: Title 27 Landfill Gas Monitoring Probes <br />City <br />Lic # Phone <br />Range R.7E. Section SEWC.3 <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />Q/HOLLOW STEM <br />1 <br />DIA. OF BOREHOLE 8"-10" [1 MULTIPLE CASINGSQ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL QGVC ❑ OTHER <br />❑ VAPOR <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED46 AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE <br />❑ PUSH POINT (GP OR CPT) <br />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. dBOLTED 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 1 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 ' nia Laws. <br />Signed Title/Company Project ManagerrIBAS & Associates, Inc. <br />Print Name Rodolfo Coto Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BYDATE ISSUED AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION 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 />PERMIT/SERVICE # INVOICE <br />14 <br />C� -- <br />1 `1`Z `l 1 j <br />'/S I 001 <br />SR#00580 <br />C-57 WC <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 11/5/07 (WEB) WELL PERMIT APP <br />