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r <br /> L) C 0 P y <br /> SAN jOAQUIN COUNTY <br /> h ENVIRONMENTAL HEALTH ❑&ARTMENE­C 9, ° 2668 <br /> fi00 East Maim Street, Stockton, CAM 95202-3029 SITE <br /> "TIGATION <br /> <, Telephone:{209)468-3449 Fax:(209)416 -3433 Web:www siaaa�. t�tx titil + ���n <br /> RV n UNIT IV <br /> �[ WELL. PERMIT APPLICATION ���� � T' <br /> NON-REFUNDABLE PERMIT_EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> 2360 East Street r,r I` Assessors <br /> W%II Location Cress Street :F Grant Line Road Cit Manteca,CA Zip 95376 Parcel# 233-46401 <br /> Oyv��John Postana CITIP Trust Address P-O.Box 672 City Manteca,CA Zip 95336 Phone#. 209-239-5033 <br /> C-57 Contractor TEG Northem California Address 11350 Monier Park Place City Rancho Cordova ZIP 95742 lis# C57-706568 Phone <br /> slc�ea,a <br /> Consultant/Sub Cntr Lee 8 Pierce,Inc_ Address. 135 South Fifth Avenue,Suite C City Oakdale,CA Lic a: Phone_zng-e.,s.eim <br /> j GIS Coordinates:X -Y-12A, Tr " _ Township 2 South Range 5 East ion 21A <br />{ 9 <br /> WORK TO BE PERFORMED: J <br /> ©NEW WELLIBORING(CPT,GEOPROBE,HYOROPUNCH,'HAND-AUGER,OTMEW) JSp ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING#_-_SVP=I through SVP OVER BORE DIAMETER <br /> t ©WELL# ©PRESSURE GROUT <br /> I ©'OTHER GROUT SPEClFI <br /> CAT 1ONS <br /> r <br /> s COMMENTS: .Temporary Sora Vapor.Pn*cs for Vapor fntws9w ASS m9mont' <br /> TYPE OF WELL INSTALLATION TYPE .,r CONSTRUCTION SPECIFICATIONS r <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 75 ❑MULMPLE CASINGS❑MULTI-LEVEL WELL.CASING DtA;_ <br /> EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING❑'STEEL ❑PVC ❑ OTHER <br /> t ®VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED©AUGERS❑HOSE <br /> ❑Alli SPARGF.IOZONE ®PUSH POINT(GP OR'CPT) GP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30`) <br /> # ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _ <br /> ❑OTHER! ❑OTHER: APPROX.BORING DEPTH 5 lee.' ❑BOLTED TRAFFICBOXOR ❑STOVE PIPE <br /> - PH 7IANDVCf0RCASING PROPOSED (WYES.IIs,sne63=15maincommentsecttwr) <br /> COMMENTS: Boring filled with hydrated benlonite whoncgmplBle <br /> NOTE: OFFSITE BORINGS REQUIRE'ACCESS AGREEMENT OR ENCROACHMENT PtRMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that Ihave prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all. Ilc le California Laws. _ <br /> r Signed "�-+" . ' Title/Company President,Lee&Pierce,Inc. <br /> Print Name Jahn P.Lane,PG6795 Date <br /> OEPARTME,N,T USE ONLY 4T�Q <br /> SITE MAP IN UNIT tV FILE,ADDRESS: C �19t?.�a-1 — `p _ <br /> WORK PLAN DATED: <br /> r <br /> APPLICATION ACCEPTED BY 7DATE 1 U 3 t' f AREA g� <br /> GROUT INSPECTION BY FINAL INSPECTIO DATE 6 J <br /> DESTRUCTION INSPECTION BY - " ~) "" DATE T4 1 <br /> COMMENTSICO DITIONS: 5::' <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMT REMITT D '; CHECK# REC%rD BY DATE PERMITISERVICE# INVOICE <br /> d>kw 1SB = ail l`� tZ• zZ- # bi3� <br /> C-57 `WC -W IVER C57 LI=TTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 105107 WELL PERMIT A <br />