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WELL PERMIT APPLICATION FORM <br />f' <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q� <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 <br />San Joaquin County Development Title, Chapter 4-1115 3 and the Standards of San Joaquin County Public Health Services, Environmental Health Dw[s on <br />Assesso' <br />WELL Location 1645 Cherokee Lane Cross StreetSanguinetticity Stockton Zip 95205 Parcel# f 19-100-05 <br />PROPERTY Owner CA Traction Company Address2201 W. Washington Citystockton Zip 95203Phone:209-466-6927 <br />gan ho <br />C-57 Contractor Transglob al Env. Address 11350 Monier Pk P1 city Lorcdova Z,p957421-i # 70656*hone#916-853-8010 <br />Geochemistry510-521-2684 <br />Consultant I Sub Contractor Hydro—Env. Tech Address2394 Mariner Sq CityAlameda Li�N/A Phor,e# <br />r <br />GIS Coordinates: x 4204400mN Y 652400mE Dr., Suite 2 Township 2N Range 6E Section 43 <br />r' <br />WORK TO BE PERFORMED <br />J5 NEVA! WELL/ BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) S DESTRUCTION (choose type below) <br />C;SOIL BORING # 1 to 6 0 OVER -BORE JJ <br />IWELL # 1 to 3 1] PRESSURE GROUT <br />"Other -Six borings by Strati ro e <br />* C57 Contractor for GW wells: Spectrum Exploration Inc., 2365 Wigwam Drive, <br />COMMENTS: Stockton, CA 95205, Lic ;✓512268, 209-465-8712 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 <br />5p MONITORING ]R HOLLOW STEM DIA. OF BOREHOLE g 0„ MULTIPLE CASINGS? 0 YES $I NO WELL CASING DIA 2.0' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS sch. 40 TYPE OF CASING. 0 STEEL PVC Q OTHER � <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10 ft TREMIE TYPE TO BE USED: AUGERS ptHOSE `\ <br />0 AIR SPARGE g PUSH POINT GROUT SEAL PUMPED: aYes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />)(MSOIL BORING O HAND AUGER APPROX. BORING DEPTH 50 ft 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />OTHER: OTHER CONDUCTOR CASING PROPOSED? No (if YES, list specifications here). (� <br />COMMENTS: Six soil borings by direct push; three ground water monitoring wells by <br />hollow stem auger. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, l shall employ persons sub�ect to <br />WORKERS' COMPENSATION Laws of California " <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company Western Reg Manager, Hydro -Env. Tech. Inc. <br />— <br />& <br />Print Name William E Motzer ' Date <br />SEE SITE MAP. IN UNIT. W;WORK ;PLAN DATED: :June 9, 2000 <br />DEPARTMENT USE ONLY <br />Issued Iss <br />Date u <br />Application Accepted By (l�t� Da—T �O C> Area <br />Grout Inspection By Date 1 C'f Final Inspection By �`�U� �' oate <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # INVOICE <br />00 <br />__- /18/20 <br />