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� k <br /> WEL PERMIT APPLICATI6N rURM <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH D UNIT IV <br /> EPARTMENT (EHD� <br /> 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> S, <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRFS 1 YEAR FROM DATE ISSUED <br /> •pplicatlon 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 /> oaquin County Development Title, Chapter 9-1115.3 and the Standards of San JoaquirCounty Environmental Health Department. <br /> 'SELL Location 5151 Almondwood DriveCross Street Oleander Assesso' <br /> Y Manteca Zip95337 Parcel# <br /> — 0- <br /> 4 ,ROPERTYOwner William Harris Address 5151 Almondwood Drive City Manteca Zip 95337 Phone# 209-239-1361 <br /> 57 Contractor Fisch Environmental Address 399 Shari's Place City Val leySPringsZip 95252 Lick- 683865Phone# 209-772-3570 <br /> onsultant/Sub Contractor Ground Zero Anal sis Inc. Address 1714 Main Street City` Escalon Lic# Phone# 209-838-9888 <br /> s <br /> .1S Coordinates:X Y Township 2S Range 7E Section 19F <br /> 'JORK TO BE PERFORMED: <br /> ]NEW WELL I BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") B DESTRUCTION(choose type below) <br /> [X]SOIL BORING# SB4 drilled to 75,ft bVCPT 0 OVER-BORE <br /> [X]WELL# MW5MW6 MW7 installed to 19 ft by Hollow Stem Au er B PRESSURE GROUT <br /> )ther: Grout Specifications: <br /> OMMENTS: <br /> _ YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'l MONITORING—I•[X]HOLLOW STEM DIA.OF BOREHOLE 8V 2" MULTIPLE CASINGS?O YES [X]NO WELL CASING DIA: 2° <br /> EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: p STEEL [X]PVC BOTHER: <br /> ?VAPOR B MUD ROTARY DEPTH OF GROUT SEAL 2.5.ft/75 ft TREMIE TYPE TO BE USED: [XI AUGERS B HOSE <br /> AIR SPARGE —�[XI PUSH POINT GROUT SEAL PUMPED: [X]Yes [XI No; (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> if]SOIL BORING B HAND AUGER GROUT SPFCIFICATIONB Neat cementlnentonite grout in boring&eseete(elcement in wells _ <br /> 'OTHER:. B OTHER APPROX. BORING DEPTH 19 ft/75 ft [X]BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> 'OMMENTS: Grout seal pumped for boring u to 75 ftbut free fall for wellsless than Three feet due to shallow roundwater <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FORI ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be dare in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California State Caws. <br /> I ' <br /> fined x TidelCompany CA Re istered Geolo st 6795 Ground Zero Analysis, Inc. <br /> i <br /> rt Name John P. Lane + Date (Z 03 <br /> DEPARTMENTUSEONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: SZ7VWOoa� '_ <br /> :ORK PLAN DATED: <br /> )plication Accepted By Date Issued Z. <br /> 101 Area <br /> Gut inspection By DateZ O Final inspection 13y" <br /> .struction Inspection By Date l <br /> JMMENTS I CONDITIONS <br /> ACCOUNTING ONLY: AID## <br /> i 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 5`d 4IM-co (030 t a3 z O <br /> -57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> a i� <br />