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n WELCPERMIT APPLICATI QJRMON SITE ! <br /> II <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAR 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV il <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San JoaquirGounty Environmental Health Department. <br /> ! <br /> WELL Location 8960 W.Walnut Grove Road Cross Street_Highway I-5 _ City Thornton Zip Assessor's <br /> Parcel#_ ODI SO Zq <br /> k . <br /> PROPERTYOwner.. Barnyard Corooration Address 6265 Crooked Stick Circle City Stockton Zip 95219 Phone# 209-95.Ii.1-1207 <br /> I <br /> C-57 Contractor__V&W Drilling Inc. Address P.O. Box 416 City Isleto� Zip 95641 Lic# C57-720904 1916777-4100 <br /> IM <br /> Consultant!Sub Contractor_Ground Zero Anal sis Inc.Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> �Y <br /> GIS Coordinates:X 121.4269°W Y 38.2256`NTownship 4N „ _ Range 5E Section 4 <br /> WORK TO BE PERFORMED: a <br /> 0 NEW WELL 1 BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) [X]DESTRUCTION(choose type below) + <br /> 0 SOIL BORING# [X]OVER-BORE(MW1,MW3) <br /> 0 WELL# [X]PRESSURE GROUT(others) <br /> *Other: Grout Specifications: Neat cement grout tremied,then pressure 4 I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> [X]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I MULTIPLE CASINGS?0 YES I]NO WELL CASING D`IA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE'TO BE USEQ: a AUGERS I� p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH— <br /> _a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> *COMMENTS: �) <br /> ii <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 E <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. li <br /> Signed x "`'— Title/Company CA Registered Geolo ist 6795 Ground Zero Analysis, Inc. t <br /> ��yy JJ i <br /> Print Name John P. Lane Date <br /> DEPARTMENT USE ONLY �! <br /> i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: i <br /> WORK PLAN DATED: <br /> f r �9Application Accepted By A�'I�_nDate Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date ? Z 9 <br /> COMMENTS 1 CONDITIONS [ems i e L'e wJ A i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> l 1.1e- l! aSR# 00 3719 <br /> C-57_ WCC WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 51/25/02 <br /> II' <br />