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SITE <br />MITIGATION <br />UNIT IV <br />WELL PERMIT APPLICATION ditM <br />SAN JOAQUIN COUNTY <br />.ENVIIWNMENTAL HEALTH DEPARTMENT (EHD) <br />304 E.'Weber, Third Floor, Stockton, CA., 95202 <br />City Zip Phone# PROPERTY Owner Cal Trans Address <br />GIS Coordinates: X Township 2N Range 7E Section 18E <br />Date Issued CI _ <br />Date -z-/ 2-vio Final Inspection By <br />ermit C-57 1/25/02 WC -WAIVER Encroachment doc <br />n../ -73Cr <br />C-57 Letter of AuthViza <br /> <br />ENVIE' 7ALTH (209) 468-3449 <br />NOR-11EFUNDABLE 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 /> <br />WELL Location 8200 N. Hwy. 99 Cross Street Foppiano City Stockton Zip 95212 Parcel# 085-310-11 <br />WORK TO BE PERFORMED: <br />ONEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGERPTHER*) [X] DESTRUCTION (choose type below) <br />0 SOIL BORING # VER-BORE <br />--pErla1E5517177=r- 0 WELL # <br />*Other: Grout Specifications: Neat cement grout of well MW2 (+' Acick• Mik.1 <br />0 A farCe ( W: HI ; A I ye-r of perml+ A <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 5010%31 r-A <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 1:1 NO WELL CASING DIA: CA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: C' <br />0 VAPOR I] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 1:1 AUGERS 0 HOSE <br />0 AIR SPARGE I] PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') . <br />['SOIL BORING g HAND AUGER GROUT SPECIFICATIONS <br />.Z- 0 OTHER: 0 OTHER APPROX, BORING DEPTH 0 BOLTED TRAFFIC BOX or I] STOVE PIPE -,-1-- <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): .---Q <br />--, <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 Ordinance )s, Rules and Regulations, and all applicable California State Laws. <br />' (-4 ( Signed x ---7-4-t L/--(L----- Title/Company RG 6795, Ground Zero Analysis Inc .-j'L -1t <br /> Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />Date <br />EINIONEWMF07.121ellIMOIDAWN1111#1411T7 <br />zo-0-3 Area <br /> Date n <br />Pa r"A- <br />ACCOUNTING ONLY <br />-re Fra.4.t. way-4r Hwy vt/frt,,,-(-4.12._ <br />AID# (0.)€r 44‘ A 4-. 06 —eir" <br />prejec k- LAqivi <br />FAC# Pk• s welt <br />A Me_ ye air, +A:3 1.-ri•i;-1-1.4);1( <br />. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 7'D DATj PERMIT / SERVICE REQUEST # INVOICE <br />0' 00 IcEzs3 a acc SR# q 1 3 0 1 ---„ <br />*COMMENTS: Pressure grout of well MW2, overdrill upper three feet <br />C-57 Contractor V&W Drilling Address 100 59' Street City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 11, <br />Consultant/ Sub Contractor Ground Zero Analysis Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />COMMENTS: <br />Print Name John P. Lane