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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ¢• a <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> •C.•.•_a •.:P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.si-gov.org/ehd UNIT IV <br /> =-0 <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 /> Bonng Assessor's <br /> =Location 1550 Industrial Drive Cross Street S Airport Way City Stockton Zip 95206 Parcel# AC/0-6 5 <br /> Property <br /> Owner Metalsa Address 1550 Industrial Drive City Stockton Zip 95206 Phone#209-983-6100 <br /> C-57 Contractor Vironex Address 5292 Pacheco Blvd City Pacheco Zip 94553 Lic# 705927 Phone <br /> Consultant/Sub Cntr ENVIRON Address 707 Wilshire Blvd,Ste 4950 City Los Angeles Lic# Phone 213-943-6300 <br /> GIS Coordinates:X 121015'16.14 W Y 37°54'36.87 N_Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING#8 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: Borings will be backfilled with a portland cement slurry(5 to 1 ratio)upon sample completion. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:NA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE NI PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NA <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 feet ❑BOLTED TRAFFIC BOX OR ❑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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a d all appli Califo nia Laws. <br /> Signed Title/Company Associate/ENVIRON International Corp. <br /> Print Na a Alma Queza(dd Date June 30,2010 <br /> DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: a <br /> APPLICATION ACCE ED BYDATE ISSUE ? I U AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 71 ND DATE <br /> DESTRUCTION INSPECTION BYCCcc AA DATE _ <br /> COMM ENTS/C O NDITI DNS: 1F5;k1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#ol,9 <br /> C-57 WC -WAlvrn C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28!09 WELL PERMIT APP <br /> P/?- <br />