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l�jll \"/ LL/1 • SAN JOAQUIN COUNTY • <br /> *NvIRONMENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> SEP 0 3 2008 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Tele h : (209)468-3449 Fax:(209)468-3433 Web:www,s'gov.org/ehd <br /> HEPAR UNIT IV <br /> PERMIT/SERVICES WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to constructand/or install the work described. This application is made in compliance with San <br /> JoaTI&C.eerkppvuckopp,bbreeJCltl gnqust.1I I �i vte ann�-T7c$koin ey�4ienuiaunty Environmental Health Department. r� qq <br /> Well Location p�3 C-• 5'F:' Cross Street � City Stockton Zip 95206 pa cel#I's ! b�'F <br /> Property Union Pacific Railroad 9451 Atkinson Street Roseville <br /> Owner Address -ter City95747 916.789.5184 <br /> _ Zip 47 Phone# _ <br /> C-57 Contractor VIIiDNEX r.LAC. Address-5�Z TdCWW 8/re{-, City PSA Lic# 70n;LlFPhone 9as •.521"/1110 <br /> ARCADIS U.S.,In 950950 Glenn 125 Folsom 916.985.2079 <br /> Consultant/Sub Cntr X(ddress City Lic# Phone <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW YELLIBORING(CPT,GEOPROBE,H DROPUNCH,HANG-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# Ge- 1O„ab, C-�10-a L/ ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> EI-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE [PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> VSOIL BORING El HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1 / ❑BOLTED TRAFFIC BOX OR E3 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (ir YES,list spedtimtlons 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 /> Regulations,and all applicable California Laws. <br /> Signedpa LL.QXX�� f Title/Company Associate Project Manager/ARCADIS U.S. ,Inc. <br /> Print Name Danielle Catlin-Wright . -Date aP• 2 0F? <br /> Q <br /> DEPARTMENT USE�ONLY <br /> - L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3% d(, ; 51-- <br /> WORK <br /> 1--WORK PLAN DATED: D Zo d <br /> APPLICATION ACCEPTED BY DATE ISSUED 11d AREA <br /> GROUT INSPECTION BY t FINAL INSPECTION BY DATE W6� <br /> DESTRUCTION INSPECTION BYtt DAT/E <br /> COMMENTS/CONDITIONS: Q" ,tzt,<,.,Lt - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Ol 85" 11/1/10V SR#0L53-? <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2e-01 11/&09(WEB) WELL PERMIT APP <br />