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WELIITRMIT APPLICATION FOAM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />AssessoCis , <br />WELL Location 5151 Almondwood Drive Cross Street Oleander City Manteca Zip 95337 Parcel# —1 30— /3 <br />PROPERTY Owner William Harris Address 5151 Almondwood Drive City Manteca Zip 95337 Phone# 209-239-1361 <br />C-57 Contractor Fisch Environmental Address 399 Shari's Place City ValleySpringsZip 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 /> <br />GIS Coordinates: X <br /> <br />Township 2S <br /> <br />Range 7E <br /> <br />Section 19F <br /> <br />WORK TO BE PERFORMED: <br />[X] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER.OTHER") <br />0 DESTRUCTION (choose type below) <br />[X] SOIL BORING # SB4 drilled to 75 ft byCPT fl OVER-BORE <br />[X] WELL # MW5, MW6, MVV7 installed to 19 ft by Hollow Stem Auger fl PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8"/ 2" MULTIPLE CASINGS?0 YES [X] NO WELL CASING DIA: 2" <br />CASING THICKNESS SCH 40 TYPE OF CASING: 1] STEEL [X] PVC 00THER <br />DEPTH OF GROUT SEAL 2.5 ft/75 ft TREMIE TYPE TO BE USED: [X] AUGERS a HOSE <br />GROUT SEAL PUMPED: pq Yes pq No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS Neat cement/bentonite grout in boring & eonerete/cement in wells <br />APPROX. BORING DEPTH 19 ft/75 ft [X] BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: Grout seal pumped for boring (up to 75 ft), but free fall for wells (less than three feet due to shallow groundwater) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />TYPE OF WELL INSTALLATION TYPE <br />[X] MONITORING-0' [X] HOLLOW STEM <br />0 EXTRACTION <br /> El AIR HAMMER/DRIVEN <br />0 VAPOR <br /> <br />0 MUD ROTARY <br />0 AIR SPARGE <br /> <br />[X] PUSH POINT <br />[X] SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <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, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name John P. Lane <br />Title/Company CA Registered Geologst 6795, Ground Zero Analysis, Inc. <br />Date <br /> (2—( LAI Cj <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRSS: Ci.S <br />WORK <br />- <br />WORK PLAN DATED: L 3 0 3 <br />IC4 (' <br />Date I / 2-4 01/41 Final Inspection By <br />Date <br />COMMENTS/CONDITIONS Necick- rt-514.7(- +or ( CA.1414 1.4,40 ("A 4- 6,0-u akotikt044q,(4-3 <br />ACCOUNTING ONLY: AID# FAC# <br />---.1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 1 464'00 C 13069 (4 !/f3 SRlit CS z-9 o <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued Area <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />1/25/02 <br /> <br />sQÔ 3 10-z -i