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WELLOERMIT APPLICATION F, ZM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />UNIT IV <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 � � <br />(209) 468-3449 U 's <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 2 2 2003 <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 coLn lianiH <br />an <br />Joaquin Count Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health De a V� �(NUItI <br />Park St. Stockton 95202Pk�i!10ES <br />WELL Location 640 N. E1DOradO Cross Street City Zip rceI# <br />PROPERTY OwnerGene Gabbard Inc - AddressP . O. Box 1260 cityStockton ZiP95201 Phone( 209) 367-6992 <br />C-57ContractorFlSCh Env. Address399 Sheris P1. cikalley Zipg525TicAA-1A -Rhone#(209)772-3570 <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules ^and Regulations, and all applicable California State Laws. j <br />4✓Si <br />Signed x Title/CompanyC-�ve��-v�C1 �C-t Ci 1� y 51►'�Z <br />k <br />Print Name 62L? Date C)Lt <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADq RESS: �� U /J • FA(��cxr eQ . <br />WORK PLAN DATED: I /1 I D -2- <br />I <br />i I <br />Application Accepted By \Date Issued Ll f L3 f D Area <br />Grout Inspection By�, v , Date S_1310:t2 Final Inspection By Date Z D T <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />S rings <br />FEE INFO <br />Consultant/ Sub Contractor Ground Zero <br />Address 1714 Main S?. Cifscalon Lic# Phone l 209) 838-9888 <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />ol2_451 hT <br />Hz�3 Lox 51wG33.5- <br />EW WEL / BORING <br />( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 OVER -BORE <br />WELL# MW -5 <br />MW -6, MW -7 0 PRESSURE GROUT <br />*Other: <br />Grout Specifications. Neat Cement <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLkTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />JZMONITORING <br />7S HOLLOW STEM <br />DIA. OF BOREHOLE 8 a" MULTIPLE CASINGS? 0 YES jR NO WELL CASING DIA: 2 <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL X(XPVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL" 1 5 ' TREMIE TYPE TO BE USED: X[JAUGERS 0 HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes Xro (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: Neat Cement <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH 35-40 M BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? No ( if YES, list specifications here): <br />0 <br />*COMMENTS: <br />1 + <br />NOTE: <br />OFFSITff BORINGS <br />REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules ^and Regulations, and all applicable California State Laws. j <br />4✓Si <br />Signed x Title/CompanyC-�ve��-v�C1 �C-t Ci 1� y 51►'�Z <br />k <br />Print Name 62L? Date C)Lt <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADq RESS: �� U /J • FA(��cxr eQ . <br />WORK PLAN DATED: I /1 I D -2- <br />I <br />i I <br />Application Accepted By \Date Issued Ll f L3 f D Area <br />Grout Inspection By�, v , Date S_1310:t2 Final Inspection By Date Z D T <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />ol2_451 hT <br />Hz�3 Lox 51wG33.5- <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit ncroac men oc 1/25/02 <br />