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4 t <br /> Ind �../ <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL_ HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 8-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> 7500 West 11th.Street Chrisman Rd Trac 95304 Parcel#�5 250 15-16 <br /> WELL Location Cross Street City__ Y_ Zip <br /> PROPERTY Owner Carl B.Navarra Address 475 West Blewett Road CityTracy Zip 95376 ph n.# (209)836-0005 <br /> C-57 ContractorSpectrum Exploration Inc Address-2365 Wigwam Drive City Stockton Zip 95205 LIc# 512268 Phone# (209)465-8773 <br /> Consultantt/Stib-eo ft Lfvr The San Joaquin Company Inc. Address 1 120 Hollywood Ave#3 City Oakland Lith# GE i 82 phonet (510)336-8118 <br /> GIS Coordinates:X 121 Des 23 sec 34 Mia w y,37 Deg,44 Min.21 Sec NTownship 2 South Range 5 East 27 <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER-) ❑ DESTRUCIl)N(choose.type below) <br /> 11 SOIL BORING# r u OVERBORE <br /> ® WELL# On-site wells X rJ ❑ PRESSURE GROUT <br /> "Other Grout Spedfications: <br /> COMMENTS: see Work Plan for Extended Site Characterization 7500 West Eleventh Street.Tracy.Caliromia dated October 2001 by The San Joaquin Company Inc.for well[orations <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONSPECIFICAT]gKI <br /> N MONITORING 1$I HOLLOW STEM DIA OF BOREHOLE-8 in- MULTIPLE CASINGSU YES®NO WELLCASING DIA: 2 in. <br /> ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASiNGTHICKNESS 0.1 in. TYPE OF CASING❑STEEL®PVC❑OTHER: <br /> ❑ VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 3'to 37' TREMIE TYPE TC)BE USED 0 Auger ❑ Hose <br /> ❑ AIR SPARGE ❑ PUSH POINT GROUT SEAL PUMPED: 0 Yes 9 No(NOTE:MAXIMUM FREE-FALL DEPTH IS 3D') <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS: Bentonite/Type 11 Portland cement <br /> ❑ OTHER. © OTHER APPROX.BORING DEPTH 22'to 51' N BOLTED TRAFFIC BOX oro STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (If YES,list specifications here)' <br /> COMMENTS: see Work Plan for Extended Site Characterization 7500 West Eleventh Street,Tracy,California, dated Oclober 2001 by The San Joaquin Company Inc.and <br /> supplemental letter dated 11/29/01 on ftie with San Joaquin County Public Health Services for individual well construction dctails <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 Ordinanc s, Rules and Regulations, and all applicable California State Laws. <br /> Signed _Tille/Company Geotechnical Engineer,The San Joaquin Company Inc. <br /> Print Name David Watkins ate 28 Feb 2002 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: M <br /> Application Acoepted B `— ate Issued , `Q.r o2 ea <br /> Grout Inspection By _. Date Final Inspection By Dates_ <br /> Destruction Inspection By Date <br /> COMMENT/CONDITIONS' <br /> ACCOUNTING ONLY: AID# EAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITISERVICE REQUEST# INVOICE <br /> -3,5011 / Q� '7Z1 I <br /> C-57 We -WAIVER C-57 Letter of Authorization to sign permit En achm nt doc 1125102 <br /> 4 <br />- -- - ---- - - <br />