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ut <br /> °PC �o ~� SAN JOAQUIN COUNTY JUL <br /> tFr <br /> EAIWIRONMENTAL HEALTH DEPARTWWRONIUr.ENT r4GATION <br /> ITE <br /> `66 `����` 0 East Main Street, Stockton, CA 95202-3024ERMIT C HE <br /> �i�ione: 209 468-3454 Fax: 2 �1ERV�C 1 <br /> coq.,- ;P P P ( ) ( 09)468-3433 Web:WWW.sigov.ora/ehd <br /> %PORN 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 fora permit to construct and/or install the o6anceP work described. This application is made in compwith 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 Grant Line Road Cross Street Corral Hollow Road City Tracy Zip 95377 Parcel# <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 - Cit ancho Cordova <br /> Zip Zip 95742 Lic#C57 938110 Phone <br /> COnsultant/Sub CntrARCADIS US,Inc. AddresS3240 E1 Camino Real,#200city Irvine Lic# Phone 714.730.9052 <br /> GIS Coordinates:X Y _ Township 2S Range 5E 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 /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:Properly destroy five GWM wells (MW-5, MW-6, MW-7, MW-8, MW-12) and one GW extraction well (EX-6) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <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)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') I �\ <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Principal Engineer / ARCADIS U.S. , Inc. <br /> Print Name Allen C. Just, P.E. Date July 15, 2010 <br /> DEPARTMENT USE ONLY t Z�lo <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I � <br /> APPLICATION ACCEPTED BY DATE ISSUED 'L(' AREA <br /> GROUT INSPECTION BY FJINAL INSPECTION <br /> DESTRUCTION INSPECTION BY 7 ATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> o �l RM0kff5 <br /> C-57 WC y -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 ':+ —WELL PERMIT APP <br />