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• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Farr:(209)468-3433 Web:wwvv.Sl ,_-gov or-g/ems r <br /> Q <br /> WELL PERMIT APPLICATION UI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY L 7 LU.0 <br /> Application is hereby made to San Joaquin County for a permit to construct andtor Install U)e wade dasuibed. This application is ILo1Yq'tlliYl;lYA¢e1M'IIAALTH <br /> Joaquin County Development Title,chapter 9.1115.3 and the Standards of San Joaquin County Envlron mental health Department. DCOAAIT/�4RVICES <br /> Walt Location 8203 East 11th Street Cross Street Access RoedlRaikoad Tracks City Tracy zip 95304 Parcel 0 5014003 <br /> rty William Borgh Address, 150 Raylan Drive City Sutter Creek zip 95685 Phonast 209-267-0269 <br /> C-57 Contractor TEG Address 11350 Monier Park Place Cfty Rancho Cordova LIc s 76569phom 916-853-8010 <br /> Co sultartVSub Crdr Stantec mess 3017 Kilgore Rd,Suite 100 Gdy Rancho Cordova LIc• Phone 916-861-0400 <br /> G43 Coordinakes:X Y ,Tovmship 16N Range 14W Section 20 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIOORIMO(CPT,GEOPROBE,HYDROPUNCH,HAHO-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> D SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL 11 ❑PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Install 1 temporary toll gas sampling point(designated SGA)to a depth of S bgs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTLLEVEL WELL CASING DIA 1/4 <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL D PVC 51 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> D AIR SPARGE)OZONE 3 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Ym (0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement backfill following vapor samplin <br /> BOTHER Vapor Probe 0 OTHER: APPROX.BORING DEPTH 5 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED If YES,rM wedMall"n armrrA WOW) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby car"that I hove prapsrad this alliplIcation and that the work will W Items I accordanea with San Joaquin County Ordlnanees,Rules and <br /> RsgulaOons,and at C��NJ�om <br /> Slgmed �/ ---- TIUe/Company Senior Geologist/Stantec <br /> Print Name Mark P.Bare <br /> DEPARTMENT USE ONLY � ��C IrO�y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �1�3 E - i�tw.ar�-L �� r� ` V <br /> WORK PLAN DATED: 1 t7 f 6' <br /> APPLICATION ACCEPTED BY _%MMC"— DATE ISSUED i [�AREA <br /> GROUT INSPECTION BY I A"Gael 6'f 6 11-DFINALINSPECTION BY I/F�t�t�h3 :— DATE l <br /> DESTRUCTION INSPECTION BY DATE S� ' <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID Is FAC It <br /> PE CODES FEE INFO AMT REMITTED CHECK 11 RECV'D BY DATE PERMm3ERVICE F 1 INVOICE <br /> 2-gv5 ZYsl41 6./;, I 6 f lv I SR# (70103 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHDQ 1111W(MB) Y U.PERMIT APP <br />