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,-,An Joaquin County G <br /> x Environmental Health Department SITE <br /> i' 4� 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT T IV <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 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 /> WELL Location 401 French Camp Rd Cross Street S. Priest Rd city Camp Zip 95231 Assessors <br /> Parcel#193-140-13 <br /> PROP <br /> OwnerW(RE Address 77 Beale St.Mail Code B24A City San Francisco Zip 94105 phone#415-973-1284 <br /> C-57 Contractor N/A PG issue for<10'HA Address City Zip Lic# Phone# <br /> Consultant/Sub CntrSECOR Address3017 Kilgore Rd City Rancho cOrduva Lic#NA Phone#916-861-0400 301 <br /> GIS Coordinates:X Y TownshipT1S RangeR6E Section14 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> p SOIL BORING# p OVER-BORE. DIAMETER <br /> p WELL# p PRESSURE GROUT <br /> p*Otheral HandAuger borings to—b lootgs GROUT SPECIFICATIONS <br /> COMMENTS:Potential former AST location <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE<3" 0 MULTIPLE CASINGS [)MULTI-LEVEL WELL CASING DIA:____ <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS / PE OF CASING: p STEEL p PVC p OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS a HOSE <br /> p AIR SPARGE/OZONE PFJ3F1=!P,-,%CPT)GROUT SEAL PUMPED: p Y s p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND GROUT SPECIFICATIONS Bentonite chips 0.5 to 5.0 bgs hydrated <br /> []OTHER:HA borings4n O R 0 bgS APPROX.BORING DEPTH5 feet BOLTED TRAFFIC BOX or a 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord=ces, es andegulations,and all applicable California State Laws. <br /> Signed x � Title/CompanyPh.D., P.G.#6048, SECOR <br /> Print NameGary D. Haeck Date4/17/06 <br /> DEPARTMENT USE ON Y �.uzT <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oe E. T��S4 <br /> WORK PLAN DATED: 'Z°` <br /> Application Accepted By Date Issued ✓'l`� Area D �� <br /> Grout Inspection By Date Final Inspection B s ~" .3 ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED C/HECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> zq0/ �OJ�I��11 -ung SR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> X2/04-02- A//f4 �6��6, <br />