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FILE{. San'Joayuln`Ctium COPY <br /> ' Environmental Health Department SITE <br /> 304 East Weber.Avende, 3rd Floor, Stgkton,CA 9520PL 4� JMGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:Iwww.sjgov.org/ehd UNIT IV <br /> APR -- � 2007 <br /> Well Permi# Application -- <br /> s. p A� q <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUaVIt�iJ!'vi4Lly i HEALTHEHEALTH � CT Q <br /> Application is hereby made to San Joaquin County for a permit.to construct and/or install the work described. fl&1 �i� IW1rGUSin compliance with San <br /> Joaquin County De pm t Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 33ll-- & south sides Assessors :�O l , <br /> WELL Location cen er of Grant Line Road' Cross.Street East Street City Tracy Zip 95376 Parcel# UV <br /> PROPERTYCity of Tracy <br /> Owner public Works Dept. Address 520 Tracy Blvd. <br /> city!!Tracy Zip 95376 Phone# <br /> 209-831-4420 <br /> � . Valley <br /> C-57 Contractor Fisch Drilling Address 399 Sheri's Place City Springs Zip 95252 Lic#683865Phone# 209-772-3570 <br /> Ground Zero <br /> Consultant I Sub Cntr Anaiysis, Inc. Address 1714 Main Street, City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X 3 Y-jV•,qZ :t. ,Township 2S Range SE Section 21A <br /> WORK TO BE PERFORMED: f <br /> )&NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# SBIB 5619,; SB20, S321`,wi'SB22, SB23 R' OOVER-BORE. DIAMETER <br /> AWELL# MWS ' ,t []PRESSURE GROUT <br /> 0*OtherGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'HOLLOW STEM DIA:.OFlBOREHOLE $° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING-THICKNESS Sch. 40 TYPE OF CASING: 0 STEEL /H'PVC O'OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2' - TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE FUSH POINT(GP orCPT)GROUT SEAL PUMPED: p Yes,J,No (NOTE: MAXIMUM FREE,FALL DEPTH IS 30') <br /> jj-SOIL BORING r0 HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 20' (MWS") BOLTED TRAFFIC BOX or STOVEPIPE <br /> CONDUCTOR CASING PROPOSED f (if YES,list specifications in comment section) <br /> COMMENTS: Soil borings will be advanced to TO' below grade, and will be grouted upon completion <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 in accordance with San Joaquin <br /> County Ordinances, Rules arm Re and all applicable California State Law . <br /> Signed x �/ TitlelCompany <br /> : ... <br /> Print Name �'R EG6RY J'• S7%4/7`Z Date 3 A r G7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: -2360 FdcI,� LOP NDN_' <br /> - <br /> WORK PLAN DATED:. 3 O <br /> Application Accepted By Date Issued Ara <br /> Grout Inspection By to Final Inspection . _ Date <br /> Destruction Inspection By DateIt 1 <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# f <br /> ° FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#' REC'D BY.. DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Spl� ° O` .2.i0 SR# <br /> C757_ WC=WAIVER_ C-57 Letter of Authorization ta;sign permit _Encroachment doc <br /> EHD 29-02-001 . f�r O 7. 5Z• <br /> 6/22104 <br />