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so.lk fyi <br />I hereby certify h <br />County Ordi <br />Signed x <br />ication and that the work will be done in accordance with San Joaquin <br />all applicable California State Laws. <br />Title/Company <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: //39(47 /0 <br />WORK PLAN DATED: AO • 2C05 <br />Print Name <br />V/A7- N0,1 <br />Azt . <br />Dat <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS . <br />Date Issued <br />Final Inspection By <br />Date <br />ORIGINAL <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c)d t <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 Joaquin County Environmental Health Department. <br />Assessors <br />Parcel# 05926010 <br />PROPERTY <br />Owner T & T Trucking Address 11396 N. Highway 99 City Lodi Zip 95240 Phone# 209-931-6000 <br />City Stockton Zip 95205 Li c# 512268 Phone# 209-465-8712 <br /> <br />C-57 Contractor Spectrum Exploration, Inc. Address 2365 Wigwam Drive <br /> <br />Consultant / Sub Cntr Brown and Caldwell 10540 White Rock Rd; Ste180 Rancho Cordova <br />Address City Lic# Phone# 916-444-0123 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />WELL Location 11396 N. Highway 99 Cross Street Morse City Lodi <br />Zip 95240 <br />GIS Coordinates: X 6343306.26 y 2212648.74 , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />U WELL # ASW-1, ASW-2, ASW-3, ASW-4, ASW-5, VEW-3 <br />a *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />El MONITORING <br />a EXTRACTION <br />0 VAPOR <br />INSTALLATION TYPE <br />U HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6 to 8 a MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: I and 3 <br />CASING THICKNESS Schedule 40 TYPE OF CASING: a STEEL I] PVC El OTHER: <br />DEPTH OF GROUT SEAL 46' and 92' TREMIE TYPE TO BE USED: a AUGERS U HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat-cement <br />0 OTHER: a OTHER APPROX. BORING DEPTH 60' and 110' BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO <br />in, <br />AMOUNT REMITTED CHECK # REC'D BY DATE P - • - , !.- T # INVOICE v oi 56 tny 3e3..v. 61.370 Ciat ?,/,r SR/beCi g# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permenefeitc,hm <br /> <br />EHD 29-02-001web <br />6/22/04