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Y O <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOA I p COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENfiltl �, <br /> 304 E. Weber, Third Floor, Stockton, CA., 95F2 <br /> (209) 468-3449 E p 2 2004 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DR 1IS9TT���'' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri Nr ' hWde in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San JoaquirGounty Environmental a Int. <br /> Assessor's <br /> WELL Location 23021 S.Santa Fe Road Cross Street Henry Rd. City Riverbank Zip 95367 Parcel# 249-060-13 <br /> PROPERTY Owner Peter Palomino and Ernesto Palomino Address 6420 7`"Street City Riverbank Zip 95367 Phone# 209-652-8240 <br /> C-57 Contractor Fisch Environmental Address 399 Shari's Place City VallevSpringsZip 95252 Lic# 683865Phone# 209-772-3570 <br /> Consultant/Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X 121°56.44'W ,Y 371 44.78'N Township 2S Range 9E Section 23 <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING(CP GEOPROBE YDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION(choose type below) <br /> [X]S NG# SB4-SB5 D OVER-BORE <br /> [ ]WELL# D PRESSURE GROUT <br /> *Other: Grout Specifications: Neat cementhentonite grout <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?D YES [X]NO WELL CASING DIA: NA <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: D STEEL D PVC DOTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: D AUGERS [x]HOSE/PIPE <br /> D AIR SPARGE [X]PUSH POINT GROUT SEAL PUMPED: [X]Yes [X]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> [X]SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Neat cement/bentonite grout <br /> D OTHER:_0 OTHER APPROX. BORING DEPTH 30 ft D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin Hees Rules and Regulations, and all applicable California State Laws. <br /> Signed x L Title/Company CA Registered Geologst 6795,Ground Zero Analysis, Inc. <br /> Print Name John P.Lane 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 Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SRU <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />