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WELL-PERMIT APPLICATION FOF00 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 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 Joaquin <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquidounty Environmental Health Department. <br /> Assessor's <br /> WELL Location 7835 Thornton Road Cross Street Hammer Lane City Stockton Zip Parcel#07749027 <br /> PROPERTY Owner Knowles Family RevocableTrust Address:P.O. Box 640. City:Woodbridge Zip:95258 Phone# 209-367-6992 <br /> C-57 Contractor V&W Drilling Address 100 Jh Street City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 <br /> Consultant/Sub Contractor Ground Zero Analysis Address 1714 Main Street City Escalon Lic# Phone#209-838-9888 <br /> GIS Coordinates:X ,Y Township 2N Range 6E Section 16 <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL!BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> [x]WELL# MW10 0 PRESSURE GROUT <br /> `Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 12%" MULTIPLE CASINGS?[X]YES 0 NO WELL CASING DIA 6 5/8-2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASINGTHICKNESS_Sch40 TYPE OF CASING: [X]STEEL [X]PVC 0 OTHER: <br /> 0 VAPOR VW2 [X]MUD ROTARY DEPTH OF GROUT SEAL 86'TREMIE TYPE TO BE USED: 0 AUGERS [X]HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [X]Yes 0 No(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat Cement Grout from surface to 86bgs <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 100' [X]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Yes (if YES,list specifications here): <br /> *COMMENTS: 6 5/8"diameter conductor casing will be installed to a depth of 80' <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 County <br /> Ordinances, Rule a�n�d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company RG.6795 Groun Zero An lysis, Inc <br /> Print Name John P.Lane Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application AcceptedBy /djjr -1b fj Datlssued S � <br /> cl Area 912 <br /> Grout InspectionBy ,"� Date C�� Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS O>ti ��Y Apw} S/1 b t& i-e— <br /> ACCOUNTING ONLY AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3&DI Fc( F�rj`�p 1606-7 46-- S ah # DO (S� <br /> -57__ WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />