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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />SITE <br />MITIGATION <br />U NIT w <br />RECENED <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AUG 4 2000 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicati <br />WELL Location 8751 E. Highway 12 Cross Street Bruella Aveeity Victor Zip 95253 ParceW <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Pbc E <br />PROPERTY OwnerDOle Food Company IncAddress 10900 Wilshire BlvdCitylos Angelezip 90024 Phone# 310-824-1023 <br />Ste. 1600 <br />Tyr- uli Health Services, n , 'ad prok* San <br />.4. I' r . <br />C-57 Contractor SpeCtr um Address 2 365 Wigwam Drive city Srocktonzip 95295Lic#512268Phone# 209 -465-8212 <br />1bty Consultant! Sub Contractor Geomatrix Address 2444 Main St. 1/2 Fresno Lic#A60145lPhone# 559-264-2535 <br />GIS Coordinates: X , Y , Township 3N Range 7E Section 4 <br />WORK TO BE PERFORMED: <br />*IEW WELL /6C7R-117".4( CPT, GEOPROBECT7-07-13UNC )HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />XSOIL BORING # OVER-BORE <br />a WELL # a PRESSURE GROUT <br />*Other: GROUT SPECIFICATION Cement-bentonite <br /> <br />COMMENTS: <br /> <br />(\ <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8" MULTIPLE CASINGS? a YES Xt,I0 WELL CASING DIA: N/A <br />CASING THICKNESS N/A TYPE OF CASING: jJ STEEL a PVC fl OTHER: None <br />DEPTH OF GROUT SEAL BOH TREMIE TYPE TO BE USED: 0 AUGERS )A1OSE <br />GROUT SEAL PUMPED: )1Nyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATION Bentonite Cement Slurry <br />APPROX. BORING DEPTH < 75 ' a BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? None (if YES, list speafications here): <br />TYPE OF WELL INSTALLATION TYPE <br />[] MONITORING ,.HOLLOW STEM <br />O EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />O AIR SPARGE a PUSH POINT <br />*OIL BORING fl HAND AUGER <br />a OTHER: U OTHER <br />COMMENTS: <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 <br />County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />* CALL THE UNIT W INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x Title/Company Senior Engineer,Geomatrix Consultants, Inc. <br />Print Name Veen Chee Foong <br /> <br />Date 8-2-00 <br /> <br />SITE MAP IN UNIT IV FILE ADDRESS NVORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By •-• - /1/ <br />Grout Inspection By (it2i-k-At•-^C <br />Destruction Inspection By <br /> <br />Date Issued <br /> Final Inspection By <br />()1 - e c2) I ci <br /> <br />Date CC) <br /> <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE - 1 - - • :•• - 4- • INVOICE <br />--)--i I 7'1 3 9 7 0 sR# 66;2-3 6, 7? <br />C-57 Letter of Authorization to sign permit ----Ericroachment_dor.--- -7/17/00 C-57 WC/WAIVER