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RECEMErrIELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY MAR 1 0 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />P ERMIT/SERVICES (209) 468-3449 <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 />Assessor's <br />WELL Location 8960 W. Walnut Grove Road Cross Street Highway 1-5 City Thornton Zip Parcel# 00/ / 0 2-Ci <br />PROPERTY Owner Barnyard Corporation Address 6265 Crooked Stick Circle City Stockton Zip 95219 Phone# 209-951-1207 <br />C-57 Contractor V&W Drilling Inc. Address P.O. Box 416 City Isleton Zip 95641 Lic# C57-720904 Phone# 916-777-4100 <br />Consultant/ Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: X 121.4269°W , Y 38.2256°N , Township 4N Range 5E <br /> <br />Section 4 <br /> <br />WORK TO BE PERFORMED: <br />O NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) <br /> [X] DESTRUCTION (choose type below) <br />a SOIL BORING # <br /> [X] OVER-BORE (MW1, MW3) <br />1:1 WELL # <br /> [X] PRESSURE GROUT (others) <br />*Other: Grout Specifications: Neat cement grout tremied, then pressure <br />• <br />COMMENTS: <br />c14 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: CI <br />CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />GROUT <br />— <br />GROUT SEAL PUMPED: a Yes <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 11 BOLTED TRAFFIC BOX or a 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x c7- Title/Company CA Registered Geologist 6795, Ground Zero Analysis, Inc. <br /> Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />TYPE OF WELL INSTALLATION TYPE <br />[X] MONITORING fl HOLLOW STEM <br />a EXTRACTION a AIR HAMMER/DRIVEN <br />a VAPOR a MUD ROTARY <br />U AIR SPARGE a PUSH POINT <br />0 SOIL BORING a HAND AUGER <br />a OTHER: a OTHER <br />a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />7._ <br />Print Name John P. Lane <br />Area qq71tor <br />Date Grout Inspection By <br />Destruction Inspection By <br />CONDITIONS 0,1.4,--e (1LLS14. <br />Date Final Inspection By <br />Date 0_7(01i <br />/14/t4-1-01-Cle 6-A-.-"C 'AXIL <br />Application Accepted By 4k4A-tia <br /> <br />Date Issued "3( i(oLf <br /> <br />ACCOUNTING ONLY: <br />0 <br />AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERD..../JIL/ SERXWEQUEST # INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per <br />