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L <br /> � 1 <br /> FEB 2.7 <br /> o • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONW "4 <br /> 600 East Main Street, Stockton, CA 95202-3029 b PERP`IT/k <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:=.s' ov.or /�tld AAI AT <br /> a � UNIT IV <br /> WELL PERMIT APPLICATION <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 <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 8203 East 11 th Street Access Road/Railroad Tracks Trac 95304 Assessor's 25014003 <br /> Well Location Cross Street City y Zip Parcel# <br /> Property <br /> Owner Wl ll lur., Ac'! O!^ Address ISV 2m t)6k 6YNvy CityJ�tAtfei 14ML Zip 56 Phone# 7'09---6�—OZ-6� <br /> C-57 Contractor TEG Address 11350 Monier Park Place City Rancho Cordova Lic# 70658 Phone 916-853-8010 <br /> Consultant/Sub Cntr Stantec Address 3017 Kilgore Rd,Suite 100 Cit, Rancho Cordova Lic# Phone 916-861-0400 <br /> GIS Coordinates:X ,Y Township 16N Range 14W Section 20 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> I@*OTHER o 4GROUT SPECIFICATIONS p, <br /> COMMENTS:_ Install 5 temporary soil gas sampling points to a depth of 5'bgs n5yu",y74(plyJggn1 ns� A oA,L 11 [6�Q I <br /> I f— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA1/4 <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC N OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 51 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes to No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement backfill following vapor samplin <br /> :9 OTHER: Vapor Probe 0 OTHER: APPROX.BORING DEPTH 5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list spedfiwtions In winment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> RegulationsNdall <br /> applicable California Laws. II� <br /> Signed l � —" V Title/Company P(V�fe t _<.e 2P +j-.+ S-Fq nt-ec <br /> Print Name Fbvt bery , n CV- -✓)S Date-1.41r; /09 <br /> 7 <br /> DEPARTMENT USE ONLY _ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: K Z O 3 n r i V My S C= <br /> WORK PLAN DATED:_1 d Ill py <br /> APPLICATION ACCEPTED BY I,(�� _ DATE ISSUED 3/40 AREA <br /> GROUT INSPECTION BY nnA - FINAL INSPECTION BY 4.4 AAA,91,!l DATE tI L <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> -Rot s5 .o� IgsssK /r'`/ SR# 56635 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMITS ENCROACHMENT DOC <br /> EHD 28-01 1115/07(WEB) WELL PERMIT APP <br />