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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 JoaquirCounty Environmental Health Department. <br />Assessor's <br />WELL Location 2360 East Street Cross Street Grantline Blvd City Tracy Zip 95376 Parcel# 233-460-01 <br />PROPERTY Owner John Pestana OTIP Trust Address P.O. Box 672 City Manteca Zip 95336 Phone# 209-239-5033 <br />C-57 Contractor Fisch Environmental Address 399 Shari's Place City ValleySpringsZip 95252 Lic#683865 Phone# 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 37° 45' 14.5" , Y -121° 25'11.5" , Township 2S Range 5E Section 21A <br />WORK TO BE PERFORMED: <br />1X] NEW WELL / BORINSz ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />/ �� [X] SOIL BORING # CPT1 and CPT2 byCPT SB12D and SB13D by direct push <br />v 0 WELL # <br />'Other: C(01 Grout Specifications: <br />COMMENTS: 3/2,523/ 4 <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />[X] SOIL BORING <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />00, <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 <br />0 HOLLOW STEM DIA. OF BOREHOLE 1.75-2" MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUTSEAL full depth TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />[X] PUSH POINT GROUT SEAL PUMPED: [X] Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER <br />0 OTHER:_O OTHER <br />"COMMENT <br />GROUT SPECIFICATIONS: neat cement grout orbentonite <br />APPROX. BORING DEPTH 35-40 feet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 Ordinances, ul s and Regulations, and all applicable California State Laws. <br />Signed x_ jt' 1 �` Title/Company CA R.G. 6795 Ground Zero Analysis, Inc. <br />Print Name John P. Lane Date May 13 2005 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Q(ocD ��) <br />_i? �}c7� �� <br />WORK PLAN DATED: 5--1 Z -,C,S <br />Application Accepted By 9Date Issued <br />Grout Inspection By 61 Date Final Inspection By <br />Destruction Inspection <br />COMMENTS / CONDI <br />Date <br />rol <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT FS EQUEST # <br />INVOICE <br />.!� ( <br />C-57 ✓ WC /-WAIVER_ C-57 Letter of Authorization to sign permit--ZEncroac en oc�,- 1/25/02 <br />