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FILE COPY <br />,o q"' �a San Joaquin County 3 <br />Environmental Health Department[71 ITE <br />600 East Main Street, Stockton., CA 95202-3029 � �= ' 41 I <br />_ GATIGN <br />(209) 468-3449 Fax: (209) 468-3433 Web:.vww,sjgov.org/ehcR 1 008 UNIT IV <br />Well Permit Application 7i� <br />NON-REFUNDABLE PERMIT EXPIRES._1 YEAR FROM DATE ISSUED VII 0(�fmFi,j r HEALTH' t } Wit a <br />,RC <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described: This apITISER/10FS. <br />plication is male in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin.County Environmental Health Department. <br />WELL Location - !�v• �l_ Cross Streett,� 5? Assessors QA •• <br />. City TRACY -Zip 953'76 Parcel# <br />PROPERT <br />Owner CITY OF TRACY Address 95 11th Street - City _ TRACY Zip 953'26 <br />Phone -4 (203i 467-1006 <br />C-57 Contractor GREGG DRIiiINC Address 950 HOWE ROAD City"RTINEZ Zip 94553Lic#656407 Phone#(925) 313-5800 <br />ADVANCED GEOENVIRONMENTAL. 837 SHAW ROAD STOCKTON -680227 <br />Consultant! Sub Cntr Address City LIC# Phone# (?09) -46-7-1006 <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE -PERFORMED. _ <br />x4NEW WELL /:BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />Xj WELL * MW -11 and MW=14 F a PRESSURE GROUT <br />0 *Other: GROUT SPECIFICATIONS <br />COMMENTS: Two off-site monitoring -wells along east and west shoulder On Adams Street, <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Xjp4dIONITORING X3VHOLLOW STEM DIA. OF BOREHOLE8.2S"�] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL x0 PVC a OTHER, <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL J L LV TREMIE TYPE TO BE USED: >tAUGERS 0 HOSE <br />0 AIR SPARGE! OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS' TYPE II PORTLAND CEMENT <br />0 OTHER: a OTHER APPROX. BORING DEPTH 22 ' AND 35' 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />M[d-14 (35') and MW -11 I22 , }CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />} <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4$ 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 Ord' s ces, Rules an Regulations, and all applicable California State Laws. <br />Signed x TitlelGompany� c �GICYl��57 ' <br />Print Name <br />DEPARTMENT USE ONLY ZVp <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 3v <br />Application Accepted By Date Issued �� Area ; <br />Grout Inspection By Da Finat Inspection By <br />Destruction Inspection By D6te <br />COMMENTS I CON[ <br />ACCOUNTING ONLY: AID# FAC# ; <br />PE CODS <br />FEE I O AMOUNT REMITTED <br />CHECK # REC'D BY <br />DAT PERMIT! SERVICE REQUEST # <br />INVOICE <br />�9 og SR# DS j) <br />c�ar� WC %F -WAIVt:R— C-57 Letter of Authorization to Sigti permit✓ "Encroachment doc� ,r— •�Li ..0$ <br />EHD 24-02-001 WEB <br />9/11/2OG7' Q /' <br />