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08/05/2004 08: 55 2094683(` FIFTH FLOOR PAGE 02 <br /> San Joaquin County <br /> Environmental Health Departmi$Ai 0 4 2004 SITE <br /> �' M{ 304 East Weber Avenue, 3rd Floor, Stockton, <br /> HEALTH MITIGATION <br /> � <br /> N" (209) 468-3449 Fax: (209) 468-3433 Web: www.sUNIT IV <br /> ES <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the worts 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 /> SQO est Hospital Assessors <br /> w <br /> WELL Location pal Road Cross Street S- Manthey Rd.City French Camp zip 95231 Parfet# 193-050.08 <br /> PROPERTY <br /> Owner San Joaquin Gencral Hospital Address 500 West H03pltal Road City FMna,cam0 Zip 95231 Phone## (209)458.6000 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant I Sub Cnir Clayton Group Services Address G920 Koh ccmc,Pamway,Suite 200 City Fiyewn ,a Lic# Phone# WS.426-2600 <br /> GIS Coordinates:X 37.8850 Y ut.zacc Township f wbrtn Pangs 1E,J1 Secllon 33 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER") Q DESTRUCTION (choose type below) <br /> x 0 SOIL BORING# 86t toSa5 (]OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: FI"a shaaow soil twrinas will De advanced using a henclauger. After Box samples are wflocted,me twangs wai be baumnao with neat comont grout <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING u HOLLOW STEM DIA.OF BOREHOLE "'A 0 MULTIPLE CA5INGS D MULTI-LEVEL WELL CASING DIA: NIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: o STEEL p PVC Il OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL uo to 4 feet TREMIE TYPE TO BE USED. p AUGERS (]HOSE <br /> a AIR SPARGE/OZONE 8 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 11 Yes x a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )U SOIL BORING X o HAND AUGER GROUT SPECIFICATIONS neat cement with free fell of up to 4 foot <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH a feet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (d YES,list specifications in comment section) <br /> COMMENTS- Five shallow soil bonnoe will be adwneed usmo a nand auger to colleel grab sell samples. After soil samples are cosecteo,the borings will be b9c4liod wrth noot comont grab <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that 1 have pr®pared 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 Title/Company senior Project ManacenClayton GrotiD 3e1vl1c" <br /> Print Name Micnaei J.Zimmerman,PE, A Date g�2! M It, <br /> DEPARTMENT USE ONLY R � + <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: e��Y <br /> Application Accepted By K!�j V70 Date Issued 'OP Oety <br /> Grout Inspection By Date Final Inspection By Date , pip DE <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC#6000 g(Q <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 00 30<h,(-'1 � <br /> C-57— WC -WAIVER^ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29.02-001 <br /> 6/2.:x04 <br />