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1/ Y <br />San Joa um Count- <br />Environmental Health Department ITE. <br />60b East Main .Street; Stockton, CA 95202=3429 _ �Fp�y�T[ON . <br />L.- _F. <br />x;(209) 468 3449 Fax {209) 468 3433 Wah www sjgov org/d , <br />`NViRUNMEM5 <br />Nl{ Well Permlt Application <br />NON-REFUNDABLE PERMIT EXPIRES�i YEAR FROM DATE ISSUED i <br />App(icationJs hereby made to'San Joaquin County.for a permit to construct andlor Instal! the work described This appkication Is made Incompliance with San <br />StandaMs,of Sari.Jaaquln County Environmental Health Department City, of Tracy <br />Joaquin County De5elwESTM ilex sTRE� 9 1115 3 and the; � k TRACY k 95376 `:A§sessors ; s <br />f T� <br />tNELL Location _ Crass Street_ AMS City ZIp PC For <br />AD 3 11014 _. .. <br />PROPERTY Tracy 5376 209 831 6400 <br />OVMierCilty. of ; Tracy -City Hall Addre 333..CIVLC CENTER PLAZA Ckty _ _ Zip 9 Phone# <br />-ALL WELL ABAI31]0hit4ENT SLAGLE `38p Basan a ey 1tr Placerville P95667c g T 4800 :948-1355 <br />:.. <br /># 48359 <br />C7 Contractor ..._ _ . Address. r " City Zi 1Jc# Phoned ., <br />A.G:E.'r+ 837 Shaw Rd. " Stockton {` xf 209-467-1006 <br />Cbnsultant /.;Sub Cnir. ... ]� _ Address _ -- City _ . !ic# •Phone# <br />1315 Coordinates X �+ , , Y ~ Township Range 'Secdon - <br />y , <br />WORK t0,8E PERFORMED f v <br />1 <br />p <br />NEW.r 1 BORING {Cp1 cEOPRoaE HYDROPl7NCW; HAIMG O ER") jj DESTRUC#ION (choose type below) <br />nSOIL BORING # + � r''� A� F OVER BORE=. DIAMETERe . 5 inch <br />WELI # PRESSURE.GROU7,.f <br />i} GRO 2 <br />'Other UT SPECIFICATIONS`l?a 1 <br />rtland -(Type 2 $ <br />.. �0 \ <br />LATIO <br />CONSTRUCTION SPECIFIGA�ONS 8 . Z 5 inch <br />' QNITOf2iNG, - OLLOW STEM _ DIA :'OF _BOREHOLE 8 .25.a MULTIPLE 'CASINGS 0 MULTI-LEVEL WELL CASING 'IA: <br />two inc <br />p D(TRACTiON ?n(.A'IR HAMMERIDRIVEN CASING THICKNESS 1/4 �� TYPE OF CASING: 0 STEEL PVC p OTHER:.. <br />s„ 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL HACKFTr TRIM' IE TYPE TO BE US <br />E ')0 AUGERS 0 HOSE <br />0AIR SPARGE! OZONE :0 PUSH POINT (GP or CPT)GROUT SF_AL PUMPED: - Yet.. 0 No (NOTE: MAXIMUWREE�;- ALL DEPTH IS 30 <br />08011- BORING 0 HAND AUGER GROUTSPECiFICATION ortland (Type II) <br />a OTHER: 0 OTHER APPROX. BORING DEPTH 20' and 35' -. I[ BOLTED TRAFFIC BOX of a -STOVEPIPE <br />CQNWCTOR C OPOSED -YE L lst apecifications in comment section) <br />COMMENTS:, Monitoring wells: KW- 6(20') MW (20'); MW -1 20;}, -I .(35')., NW -11 (20') <br />NOTE:..OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS: - <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be dobe In accordance with Sart .ioatidih <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Project Manager/A.G.E. <br />Signed x 7iue1Comparry <br />William Little .26 January 2010 <br />Print Name - : Date _ ... <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:. _-- ._ . 5 �• . <br />WORK PLAN DATED:. -- O. -- <br />Applicatipted By a "date issued 5 - Area <br />on Accepted <br />Grout lnspectlon Ely' ate Final Inspection By Dater° 'y �l t� 2Oi6 <br />Destruction lns.ectlon B Date <br />COMMENTS1'CONDITIONS: a <br />ACCOUNTING ONLY: AID# FACS <br />PE CODES + <br />FEE INFO AMOUNT REMITTED <br />_._ <br />CHECK # RE C'D BY DAT PERMIT 1 SERVICE REQUEST # INVOICE <br />r <br />0. <br />C-57 ✓✓ WC✓ -WAIVER) C-57 Letter of Authorization to sign permit Encroachment dac✓✓. <br />EHD29-02-o0t WEB <br />Com: ��raroorS <br />9/11/2007 <br />