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,aP,.q V INE•�oG SAN JOAQUIN COUNTY <br /> ?{ VIRONMENTAL HEALTH DEPARTMENT 4 SITE <br /> _ �\\ p 20 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> � 1� Tion e: 209 468-3454 Fax: 209 468-3433 Web:www.s' ov.or /ehd <br /> �•.;_,1.� P ( ) ( ) <br /> BAR 3 1 2010 WELL PERMIT APPLICATION UNIT IV <br /> E�yVIRQNt, <br /> CENT - FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ���� <br /> Application is hereby PE(R$Ae in 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 /> Well Location Grant Line Road Cross Street Corral Hollow Road Cit, Tracy -Zip 95377 Parcel#Assessor's�21� 0ZD-�0 <br /> Property 11 o p4-OZp/.10 <br /> Owner 6ZVfAW KAddress 33 G city _ Zipyf3� Phone# 209.a l (o 40 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle CityRancho ordova?Ap 95742 Lic#C57 938110 Phone <br /> Consultant/SubCntrARCADIS US,Inc. AddresS32�4a0 ,El Camino Real,#200city Irvine Lic# Phone 714.730.9052 <br /> GIS Coordinates:X_ _ 'Y _ �[• `[S� _,Township 2S Range 5E Section 20 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPRnRF HvnRr]PUNCH.HAND-AU ER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> El <br /> ❑SOL B# RING# H� �.2' , -3/ ElOVER-BOREDIAMETER <br /> /j ElPRESSURE GROUT <br /> El*OTHER <br /> C,6 /M GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS hydropunch brigs to X�feet bgs. Install temporary 1-inch diamet rpre-packed screens. <br /> TYPE OF WELL C INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING El HOLLOW STEM DIA.OF BOREHOLE M ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ^ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N/, TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL F TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP DR CPT)GP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUMF�LDEPTH IS 30') <br /> ❑SOIL BORING HAND AUGER f eet bgs GROUT SPECIFICATIONS �� r, `/Lwt 14.P <br /> I@ OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES iFeatioCs in comment section) <br /> COMMENTS:Pre-packed screens to be removed and boreholes to be backfilled with entonite(upon completion. <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,and all applicable California Laws. <br /> Signed Title/Company Principal Engineer / ARCADIS U.S. , Inc. <br /> Print Name <br /> Allen C. Just, P.E. Date 3 <br /> DEPARTMENT USE ONLY z96G <br /> �C01 , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C.L <br /> WORK PLAN DATED: —� 12-AO 1>�d 9 <br /> APPLICATION ACCEPTED BY DATE ISSUED /Q <br /> �/O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS:, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED GCHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2,3Og �$' OF.�o�ot�— �'i� 'S•3t-tc7 R# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACH;9AMITAPP <br /> C <br /> EHD 29-01 10/28/09 E1d <br />