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• > <br />AQut" SAN JOAQUIN COUNTY 1UG tij 2009 <br />ENVIRONMENTAL HEALTH DEPAR T;T.,R ��;TH SITE <br />�,�„ •I I;�,,I�11 i tic, <br />600 East Main Street, Stockton, CA 9520 '- 4,,1 i ;�LR��'I^ES MITIGATION <br />P . Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: �siiaoy.orca/ 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 South Austin Rd Cross Street Newcastle Road City Manteca Zip 95336 Parcel # 201-06-1 <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 CntrHerst & Associates Address4630 S. Hwy 94-N. Outer Road City St. Charles, MO Lic # <br />GIS Coordinates:X 635629 <br />Y 2144880 <br />, Township 1 South Range 7 East <br />WORK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />❑ SOIL BORING# <br />® WELL # EW -3B <br />❑ *OTHER <br />CO <br />TYPE OF WELL <br />❑ MONITORING <br />® EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />INSTALLATION TYPE <br />❑ HOLLOW STEM <br />❑ AIR HAMMER/DRIVEN <br />® MUD ROTARY <br />Phone 636-939-9111 <br />Section 3 <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 13 Inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 6 Inch <br />CASING THICKNESS Sch 80 TYPE OF CASING: ® STEEL ED PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 0-115 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 />❑ HAND AUGER GROUT SPECIFICATIONS 3 x 94# Portland cement mixed with 100 gallons of water <br />❑ OTHER: ❑ OTHER: <br />COMMENTS: <br />APPROX. BORING DEPTH 150 feet ❑ BOLTED TRAFFIC BOX OR M 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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulatio , d a I appli a Cali rnia Laws. <br />PAYMENT <br />Signed l^4o Title/Com anY Staff Geolo Ist/Herst &Associates, IncRI=7Qcn <br />1r r•) <br />Print Name Rachael D. Haynes Date 8/5/2009 <br />AUG 0 7 2009 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY C= -i DATEISSUED <br />s <br />GROUT INSPECTION BY �'r�'� ul/� .'"� FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />IVr,2 <br />IH1117 <br />SAN JOAQUIN COUNTY <br />FNylann�,��� <br />HEALTH DEPARTMENT <br />1)' AREA <br />/�-'/C—DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED CHEC <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />LWc'\S <br />©o <br />9,9.6-0 \ <br />- <br />t6Gl <br />SR#.5900 <br />C-57 WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVLK L:5/ Lt I I tK Ur AU I HUKILAI IUN I U Z51UN NtKMI I tNL:KUAL:HMtN I JUL; <br />WELL PERMIT APP <br />