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• 0 <br />�oPau'" co SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT IF <br />l 600 East Main Street, Stockton, CA 95202-3029 R�R N <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd btfp qP irT2WQ �j/�Q <br />WELL PERMIT APPLICATION SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DEPARTMENT <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 />2500' E of Newcastle Rd. Along Assessor's <br />Well Location NCYCC S. Perimeter Rd. Cross Street New Castle Road City Stockton Zip 95215 Parcel # 181-150-08 <br />Property <br />Owner Forward Incorporated Address 9999 S. Austin Road City Manteca Zip 95336 Phone # 209-982-4298 <br />C-57 Contractor Precision Sampling, Inc <br />Consultant/Sub Cntr Herst & Associates, Inc. <br />GIS Coordinates: X 6361665.42 <br />Address 2365 Wigwam Drive <br />4630 S. Hwy 94 - N. Outer Rd. <br />Y 2146446.76 <br />City Stockton <br />City St. Charles <br />, Township 1 North <br />WORK TO BE PERFORMED: <br />Z NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />❑ SOIL BORING# <br />m WELL # AMW-136 <br />❑ 'OTHER <br />COMMENTS: <br />TYPE OF WELL <br />V1 MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER: _ <br />COMMENTS: <br />INSTALLATION TYPE <br />❑ HOLLOW STEM <br />❑ AIR HAMMER/DRIVEN <br />66 MUD ROTARY <br />209-465-8712 <br />Zip 95205 Lic # 636387 Phone <br />Lic # <br />Range 7 East <br />Phone 636-939-9111 <br />Section 34 <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 -inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 -inch <br />CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL m PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 0-149 TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: la Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER GROUT SPECIFICATIONS 7 x 94# Portland cement: 100 gal. water <br />❑ OTHER: <br />APPROX. BORING DEPTH 175 ❑ BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 />Regulation nd all a plic ble California Laws. <br />��� Project Geologist, Herst &Associates, Inc. <br />Signed Title/Company <br />Print Name David A. Vasbinder Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DA <br />APPLICATION ACCEPTED BY DATE ISSUED <br />GROUT INSPECTION BY �� FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />rz AREA <br />DATE i Ii QY� <br />ACCOUNTING ONLY: AID # <br />FAC # <br />PE CODES <br />FEE INFO AMT REMITTED <br />CHECK # <br />RECV'D BY DATE <br />PERMIT/SERVICE # <br />INVOICE <br />4441 <br />S1o1 S <br />SO a $ <br />SR#OCA <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG <br />EHD 29-01 11/5/07 WELL PERMIT APP <br />