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: <br /> VY <br /> F1 <br /> 2 <br /> SAN JOAQUIN COUNTY <br /> "l, D ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Mala Street, Stockton, CA 95202-3029 MITIGATION <br /> M10 <br /> T h e:(209)468-3449`Fax:(209)468-3433 Web:www.sigov-ofglehd UNIT IV <br /> ENVIRONMENT HEALTH I� WEILIJKPERMIT APPLICATION . <br /> -PERMIT/SERVICES is � ; 3 Chi'- (_b E <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <br /> Application is hereby made l4 San JoaquinCounty for a permit to construct and/or install the worts 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 /> N.Side Grant Line Rd. -160`(Wast"of East Street Tra CA 95376 Assessors Y71 <br /> Well Location Grass Street City cy, Zip Parcel# "A <br /> Property City of Tracy Public WorksAddress ouCity cY.CA Zip Phone <br /> 520 Tracy Boulevard Fra 95376 209-8314420 <br /> # <br /> C-57 Contractor Fisch Environmental Address 3150:Johnson Road City Hydesville Zip 95547 Lie# C57-683865 phone. <br /> ";I 797.7es•96W <br /> CnnsultantlSub Car Lee&Pierce,Inc. Address 1135 South Filth Avenue,Suite C City Oakdale,CA Lie# Phone 2na84e-e270 <br /> z <br /> GIS Coordinates:K 3 Y `�1 • Township 2 South Range 5 East Section 21A <br /> WORK TO BE PERFORMED: <br /> ©NEW WELWBORING(CPT,GEOPROE3E,HYbROPUNCH,'HANt)2AUGER„OTHER•] <br /> ED SOIL [�]DESTRUCTION(CHOOSE TYPE 9ELawy <br /> SOIL BORING# I [�OVER-BORE DIAMETER �I►�lrs1 <br /> ❑ LL# i ❑PRESSURE GROUT <br /> ©'OTHER GROUT SPECIFICATIONS reset ci ntwm V <br /> `� <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE :$CONSTRUCTION SP CIFICA ION�q <br /> Q MONITORING OLLOW STEM DIA,OF BOREHOLE ©MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OIA: <br /> ❑EXTRACTIONO AIR HAMMEROR1VEN, �', 4 CASING THICKNESS __ _TYPE OF CASING:©STEEL 0 PVC © OTHER <br /> ❑VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL __TREMIE TYPE TO BE USED 0 AUGERS©HOSE <br /> Q AIR SPARGE/OZONE p PUSH POINT(GP OR CPTj''. •���1'rrGROUT SEAL PUMPED:®Yes ©No (NOTE:MAXIMUM FREE-FALL DEPTH.IS 30') <br /> r <br /> Q SOIL BORINGNI?AU <br /> © R GROUT SPECIFICATIONS Nast Ccmam Grout <br /> ©OTHER: OT Eft: PPROX:BORING DEPTH 20 feet Fi <br /> +'CONDUCTOR CASING PROPOSED O BOLTED T arced C BOX me e STOVE PIPE <br /> . ( YES,ilst specirscstians in oorninen!acixkn) <br /> COMMENTS: r, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS t <br /> 48 WORKING.HOURS NOTICE REQUIRED FOR hINSIPECTIONS <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,and all Applicable California Laws_ i 1 .1 R It <br /> Signed Title/Company Vice'President,Lee&Pierce,Inc. <br /> Print Name John P.Lano,PG6795 l Date ol i`d I ~ <br /> + ' DEPARTTmr=NT USE ONLY,; (3 - <br /> SITE <br /> SITE MAP W UNIT IV FILE,ADDRESS: C �r # <br /> D I <br /> WORK PLAN DATED: i <br /> APPLICATION ACCEPTED BY it DATE ISSUED _- d'L 7—f G .AkEA <br /> GROUT INSPECTION <br /> By FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY- DATE <br /> COMMENTSICONDITIONS: ? <br /> ACCOUNTING ONLY: - AID# r:h 1 'F FAC# iI: <br /> PE CODS FEE INFO AMT REMITTED CHECK C RECWD BY € DATE PERMITISERVICE*' INVOICE <br /> C 7 IMC -WAIVER C51[LETTER OF AUTHORIZATION TO SIGN PERMIT ENC FH lQENT DOC <br /> EHD 2"1 1 i1WU7 ._8 6 <br /> OPY <br /> F1 <br />