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V&LL PERMIT APPLICATION pORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 612 W.11'"St. Assessor's Cross Street Roosevelt St. City Tracy Zip 95376 _Parcel# <br /> PROPERTY Owner Souza Realty&Development Address 105 E.101h St. City Tracy Zip 95376 Phone# 209-835-8330 <br /> C-57 Contractor V&W Drilling Address 100 Fifth Street City Isleton Zip95641 Lic#720904 Phone# 916-777-4100 <br /> Consultant/Sub Contractor-Ground Zero Analysis.Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-t - <br /> GIS Coordinates:X Y_ Township--LS_S Range 5 E Section 20/21/28/29 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [X]DESTRUCTION(chc <br /> 0 SOIL BORING# [x]O <br /> WELL# 0 PR O Y <br /> 'Other: Grout Specifications: <br /> COMMENTS: Destroying existing 2"dia.monitoring wells MW1,MW2, and MW3 by over drilling and grouting. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � j <br /> [X]MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?0 YES ONO VVI <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PV1 � <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: J 7 I 11G <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE• [ / <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x— � Title/Company CA Registered Geologist 5795 Ground Zero Analysis,Inc. <br /> Print Name John P.Lane Date <br /> "DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( I 2 vv eS f 11-dZ sfrre,�t . Tra e.v . C k 9S3 ' G <br /> WORK PLAN DATED:/ A U Q U S f 19 7-0e)4 <br /> Y <br /> Application Accepted By I G f D Y;nYin G Date IssuedA[J a u� 25- <br /> 2-004 Area 145-9 <br /> Grout Inspection By 14,4-air'- Date7 e Final Inspection By Date <br /> Destruction Inspection By y: ( mC ate Q <br /> COMMENTS/CONDITIONS: De- Si Y E i - W-3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 # 60. 00 n6o. oo I SR# 00 393 gs <br /> C-57,_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />