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n Joaquin,County y <br />Envirom,ental Health ,Depa,,tment"� . SITE <br />304 East Weber Avenue, 3rd A60b r, Stockton, CA 952R j TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or UNIT 11/ <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I; <br />SEP 14 2007 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ LPV4Ni1rHfALj-Hn <br />compliance with San <br />Joaquin oy�ty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County En�ironmen E� <br />aeu r'b 95 �, ` / /i Assessors <br />WELL Ill!l/000catio;- J W ` - TCross Street _:ty Tracy.` -Zip 95.376 Parcel#ROW. <br />PROPERTY r <br />Owner City of Tracy Address 333 Civic Center Plaza. City Tracy Zip 95376 Phone# (209) 831-6800 <br />C-57 Contractor AGE/ Envi roprobe Address 837 Shaw Road City Stockton Zip CA Lic# 680227Phone# (209) 467-1006 <br />Consultant / Sub CntrAdvanced GeoEnvironmentai Address 837 Shaw Road City Stockton L'1C# 660227 Phone# (209)467-100.6 <br />r <br />GIS Coordinates: X37, Y _124.gZ�6� Township Range Section <br />WORK TO BE PERFORMED: <br />b NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") O DESTRUCTION (choose type below) <br />s SOIL BORING # 6 0 OVER -BORE, DIAMETER <br />D WELL # D PRESSURE GROUT <br />D "Other GROUT SPECIFICATIONS I <br />COMMENTS. -six off-site soil borings, 4 in middle of Adams St and 2 along west sidewalk (encroadhment permit attached) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br />D MONITORING a HOLLOW STEM DIA. OF BOREHOLE -1 _25"n MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />D EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS n/a TYPE OF CASING: O STEEL O PVC O.OTHER: n/a <br />D VAPOR O MUD ROTARY DEPTH OF GROUT SEAL 251 TREMIE TYPE TO BE USED: D AUGERS D HOSE <br />0 AIR SPARGE/ OZONE f9 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes D: No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />{ SOILBORING { D HAND AUGER GROUT SPECIFICATIONS type I/Ii _portland cement <br />D OTHER: O OTHER APPROX. BORING DEPTH 25' O BOLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED n/a (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan I and' egulations, and all applicable California State Laws. <br />Signed x Title/Company Vice, President r <br />Print Name Roberty' Marty Date 9-14-07 <br />I' DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:____ <br />WORK PLAN DATED: <br />Application Accepted By Date Issued �� Area, Qa, <br />]` <br />Grout Inspection By tk <br />Destruction Inspection By <br />COMMENTS 1 CONDItIONS: <br />Final Inspection <br />Dale <br />,a <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT 1 SERVICE REQUEST # <br />INVOICE <br />O a <br />a �A <br />?(PZ32r <br />-i <br />SR# (� �55� <br />C-57 ✓ WC ✓WAIVER C-57 letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 �G, • D 7. ? ;�o <br />6122104 <br />