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HEALTHENVIR � <br /> SAND�+ VE Rp VEE�L PERMIT APPLICATION SRM SITE <br /> SAN Jam, B+EP, A 0�3i� <br /> 3®� E MITIGATION <br /> STOOKTON CA 95202-270$ SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 andlor install 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 /> Assessor's <br /> WELL Location 612 West 11'h Street Cross Street Roosevelt City Tracy Zip 95376 Parcel# <br /> 3 1 ri" <br /> PROPERTY Owner Souza II LLC Address 105 East 10'°Street City Tracy Zip 95376 Phone# 209-835-830 3,�1 <br /> C-57 Contractor Vironex Address 2110 Adams Avenue City San Leandro Zip 94557 Lic# 705927 Phone# 510-568-7676 <br /> Consultant/Sub Contractor Ground Zero Analysis Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> [X]SOIL BORING#SB1 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1 '/_" MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Up to surface grade TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE [X]PUSH POINT GROUT SEAL PUMPED: 0 Yes [XI No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [X]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat cement/bentonite <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 35 ft 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: A tremmie pipe will be used to place grout seal to surface <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ces Rules and Regulations, and all applicable California State Laws. <br /> Signed x ` Title/Company CA Registered Geologst 6795 Ground Zero Analysis Inc. <br /> Print Name John P.Lane Date _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4, 12 wast 1 I}-'- <br /> WORK PLAN DATED: JoAuarW 22 2004 <br /> Application Accepted By L Date Issued M r 2,0 0 4Area-145 <br /> Grout Inspection By Date & 04 Final Inspection By to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTIN:FEE <br /> NLY: AID# <br /> PE CODES INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35D ( Sq.oO 89. 0L D13314 5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />