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44 « ti� <br />San Joaquin County <br />Environmental. Health'Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax:. (209) 468-3433 Web: www.sjgov.org/chd <br />FILE COPY <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR6M DATE ISSUED �2— + 4�3 <br />Application is hereby made to San Joaquin County for a permit to construct and/or instatl 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 />WELL Location 95 11TH STREETCrosADAMS TRACY 95376 Assessors233-130-27s Street City Zip Parcel# <br />PROPERTY ,u <br />Va ' . ' <br />Owner JOSEPH PANETTA Address 95 11TH'STREET ''i, City TRACY Zip 95206 Phone# (209) 467-1006 <br />C•57Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lim 656907Phone#(925) 313-5BQ0 <br />Advanced GeoEnvixonment 11 837 SHAW ROAD STOCRTON: fi80227 (209) 467-1006 <br />Consultant/ Sub Cntr ddress City Lic# Phane# <br />GIS Coordinates: X 37�]• r 6 y—i 21 • y2 Township Flange Section <br />X4NEW WELL/ BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER*.) ' a DESTRUCTION (choose type below) <br />a SOIL BORING # <br />x)gVVELL # MW -12 AND MW -13 a OVER -BORE. DIAMETER <br />a PRESSURE GROUT <br />p'Othor GROUT SPECIFICATIONS <br />C0V1MENTS: rt,V on-site monitoring wells located approx. 15' fxom the buildings north gall. <br />_TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />xx70 MONITORING xxff HOLLOW STEM DIA. OF BOREHOLE B • 25 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING <br />a EXTRACTION 0 AiR HAMMERIDRIVEN CASING THICKNESS—— TYPE OF CASING: a STEEL Q PVC Q OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; )ffAUGERS p HOSE <br />a AIR SPARGEI OZONE © PUSH POINT (GP or CPT)GROUT SEAL PUMPED:} p Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING .0 HAND AUGER GROUT SPECIFICATIONS TYPE .II PORTLAND' CEMENT <br />a OTHER:. ® OTHER APPROX. BORING DEPTH 22' AND 35' <br />BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED (i€ YES, list specifications in comment section) <br />COMMENTS: MW -12 (221) AND MW -13 (35') , <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 Ord' aces, Rul Regulations, and all applicable California <br />It to Laws.. <br />Signed x Title/Company <br />Prim Name �' Q i`i� 76t— Date � 1a2 1 6 <br />SITE MAP IN UNIT IV FILE, ADDRESS: ' <br />WORK PLAN DATED: 30t 1c <br />DEPARTMENT USE ONLY " <br />-9,!5 ` 41. //•°'- V <br />2 <br />ttiav D /�oP <br />Applicatlon Accepted By Date Issued Area - <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D By. <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />6 <br />3� <br />SR# ,p 36 <br />G -b7 ✓ WC"-WAIVER— <br />EHD 29-02-001 WEB <br />9111/2007 <br />C-57 Letter of Authorizotion to sign permit ✓Encroach ment doc,-4',W- <br />