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San'Joaqiftriounty <br /> Environmental Health Department �TE <br /> 304'East Weber Avenue, 3rd Floor, Stockton,CA 95262 ATION . <br /> (209)468-3449 Fax:(209)468-3433 Web:-Www.sjgov.org/ehdA,PR <br /> Z007UNIT IV <br /> R . Well 'Perm[t Application1V�1' i)'?ir,:F�i fiEAiTr <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM,T/JEROGES Q 1 V <br /> Application is hereby made to San Joaquin County for a permitio construct andlor install the work described. This application is made in comptiance 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 Grant LineCRd Tracy 95376 <br /> Assessors <br /> 233-460-01 r <br /> WELL Location CPoss Street City Zip " Parcel# <br /> PROPERTY John Pestana <br /> Owner QTIP Trust Address PO Box.1672 '' i Cityi Manteca Zip 953361 Phone# 209-239-5033 <br /> Valley <br /> C-57 Contractor Fisch Drilling Address 399'Sheri_ s Place City Springs Zip 95252Lic#683865 Phone#209-772-3570 <br /> Ground Zero <br /> Consultant I Sub Cntr A�inalvsis, Inc. Address: 1714=Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X31. Y~lZl• .Township 2S Range 5E Section 21A <br /> WORK TO BE PERFORMED: <br /> rEW WELL 1 BORING (CPT,GEOPROSE,HYDRO PUNCH,HAND-AUGER,OTHER")" 0 DESTRUCTION (choose type below) <br /> SOIL BORING# SB17 i �i` 0 OVER-BORE. DIAMETER <br /> WELL# MW4 0 PRESSURE GROUT <br /> *Other . GROUT SPECIFICATIONS <br /> COMMENTS:' — <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 <br /> 11 <br /> MONITORING 'HOLLOW STEM DIA:'"OF,BOREHOLE 8" O'!MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS! Sch. 40 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY. DEPTH'OF GROUT SEAL 2 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Dyes ANo {NOTE: MAXIMUM FREE-FALE'bEPTH is 30') <br /> fSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH_ 201 ;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CON"DUCTOR CASING PROPOSED 'r (if YES,list specifications in'comment section) <br /> COMMENTS: Boring SB17 will be advanced tol10' 'helow grade;."and will be grouted upon completion. <br /> NOTE: OFFSITE BORINGS REQUIRE"ACCESS AGREEMENT OR ENCROACHMENT,PERMITS. <br /> i 48 WORKING HOURS NOTICE REQUIRED FOR INSPECT#ONS. <br /> I hereby certify that I have.prepared this application and that the Work will'Ibe done in accordance with San Joaquin <br /> County Ordinances, Rules an egula ions,and"all applicable California State Laws. <br /> Signed x Title/Company xo z axT 4,-✓s,> 04, �-VA•c.Y5 <br /> Print Name (a Y Date 2? <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2360 C:z <br /> I WORK PLAN DATED: 0 <br /> Application Accepted By s Date Issued ! ' YQ Area <br /> Grout inspection ByDate 0 Final ilnspectiorntBy r� <br /> Destruction Inspection By Dae <br /> COMMENTS 1 CONDITIONS: I <br /> ACCOUNTING ONLY: AID# FAC# <br /> 17;PE CODES FEE INFO AMOUNT REMITTED CHECK# {' RECD BY DATE J PERMIT f SERVICE REQUEST# INVOICE <br /> 3 w Q1 r� Z.p� SR# Sa/(�aJS <br /> C-57^ WC=WAIVER_ C-57 Letteraof'Authorization to sign p&-mit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />