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i PquIN r <br /> SAN .10AQUIN COUNTY r,r� ILE � <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> N.. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s ov. 1 na V <br /> �%FOR <br /> WELL PERMIT APPLICATION InI12MR�1/MIILU <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „11 5 2010 O� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a I' ryp���( �+�j ithal <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental HealtF �fIh1�H MM11r0fgVAL n <br /> Grant Line Road Corral Hollow Road Trac p53WIITp3 <br /> Well Location Cross Street City y Zip 5 arcel <br /> Property <br /> Owner City of Tracy Address 333 Civic Center Plaza City Tracy Zip 95376 Phone# 209.831.6400 <br /> C-57Contractor Cascade Drilling Address 3632 Omec Circle CityRancho CordovaZip 95742 Lic#C57 938110Phone <br /> Consultant/SubCntrARCADIS US,Inc. Address3240 E1 Camino Real,#200city Irvine Lic# Phone 714.730.9052 <br /> GIS Coordinates:X 3:7: Y —(2-1- -- Township 2S Range 5E Section 20 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ELDESTRUCTION(CHOOSE TYP BEL W) <br /> D SOIL BORING# MR 2 etn& i P&OVER-BORE DIAMETER L!t <br /> ❑WELL# ` PRESSURE GROUT <br /> ❑'OTHER ( ` GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: hydropunch � to Wfeet bgs. Install temporary 1-inch diameter pre-packed screens. \ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS• v <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)GP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING HAND AUGER 8 feet bgs GROUT SPECIFICATIONS <br /> E)OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:Pre-packed screens to be removed and boreholes to be backfilled with bentonite upon completion. C\ <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an II app!able Califor is Laws. <br /> Signed Title/Company Principal Engineer / ARCADIS U.S., Inc. <br /> Print Name Allen C. Just, P.E. Date April 14, 2010 <br /> � �y�,/DEEP_ARTMENNT USE ONLY <br /> / �Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "� 16-1 � 'I <br /> WORK PLAN DATED: 4� - 1,7—AA✓ GP <br /> APPLICATION ACCEPTED BY DATE ISSU l�ly�, AREAU_ <br /> GROUT INSPECTION BY FINAL INSPECTION B ''� "� DATE 4 AVV 1U <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 /> 29D bb 60. -1546 SR# <br /> 3-57 WC -WAIVER C57 LETTEFrOF AUTHORIZATION TO SIGN PERMIT �E/NJJ��CR/Og�ACH E.(JT DOC <br /> EHD 29-01 10/28/09 C U' `� t WELL PERMIT APP <br />