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San Joaquin County C01PT <br /> Environmental Health Department SITE <br /> < 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 If MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT Ib <br /> Well Permit Application <br /> J <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> .� Assess <br /> WELL Location 401 French Camp Rd cross street S. Priest Rd city French Camp Zip 95231 parceIN 1%30-140-13 <br /> PROP <br /> Owner E Address 77 Beale St.Mail Code B24A CiiySan Francisco Zip 94105 Phonex415-973-1284 <br /> .� C-67 Contractor N/A PG issue for<10'HA Address City Zip Llc# Phone# <br /> Consultant/Sub CntrSECOR Address 3017 Kilgore Rd CityRdnonoC"Ovs Llc#NA phones918-861-0400301 <br /> GIS Coordinates:X Y TownshlpT1 S Range R6E Section 14 <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q Othgriv Hano Auger oonfWjTT67'-;5 ° GROUT SPECIFICATIONS <br /> COMMENTS:Potential former AST location _ <br /> J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE�3t— 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS E OF CASING: []STEEL n PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUTSEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE CPT)GROUT SEAL PUMPED: Q Y s Q No I(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS Bentonite chips 0.5 to 5.0 bgs hydrated <br /> u <br /> Q OTHER:HA borings Q bgS APPROX.BORING DEPTHS feet l]BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinallcqll, es and egu!ations,and all applicable California State Laws. <br /> Signed x le/CompanyPh.D., P.G.#6048,SECOR <br /> Print NameGary D. Haeck Date4/17/06 <br /> DEPARTMENT USE ON <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6. <br /> WORK PLAN DATED: 'L(►- O <br /> Application Accepted By Date Issued Ob Areae <br /> Grout Inspection By Date Final Inspection By Date <br /> .� Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> W <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> `J C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ <br />