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°Aq�ly SAN JOAQUIN COUNTY <br /> 2 t,�• ENVIRONMENTAL HEALTH DEPARTMENT <br /> N tMITIGATION <br /> SITE <br /> r �(� 600 East Main Street, Stockton, CA 95202-3029 <br /> i✓J„D elephone:(209)468-3454 Fax:(209)468-3433 Web:www.sjgov orwehd UNIT IV <br /> F R <br /> N 1 7 Z9;0 WELL PERMIT APPLICATION <br /> EN 1 0 y��5�/�- 1 p 'q NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J a I ic }t��t(hj� to+ San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> CC 4 Title,chapter -1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Lofcatlo� Z SS N, ross Street �<-C Trac Assessors <br /> Property City y Zip 95377 Parcel# 6a <br /> Owner- City of Tracy Address 333 Civic Center Plaza City Tracy Zip 95376 Phone# 209.831.6400 <br /> Cascade Drilling, L.P. <br /> C-57 Contractor Address 3632 Omec Circle CityRancho CordovaZip 95742 Lic#C57 938110 Phone <br /> ConsultantlSubCntrARCADISrIUS, <br /> /Inc. Address3240 El Camino Real,#200City Irvine Lic# Phone 714.730.9052 <br /> GIS Coordinates:X _�J7 -Y Township 2S Range 5E Section 20 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Q SOIL BORING# HB-2 and HB-4 ❑OVER-BORE DIAMETER <br /> ❑OTHER El PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD N <br /> COMMENTS:'rwO (2) hydropunch borings to 15 feet bgs. Collect soil samples and groundwater grab sample. <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 c <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POIfdT(GP OR CPT)GP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING HANDAUGER 8 feet bgs GROUT SPECIFICATIONS <br /> SOIL <br /> ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Boreholes to be backfilled with bentonite 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 _� Cj---k_ Title/Company Principal Engineer / ARCADIS U.S., Inc. <br /> Print Name Allen C. Just, P.E. Date June 15, 2010 <br /> ,r DEPARTMENT USE ONLY Z�/� <br /> c. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: e e54 I�- Z-fJ <br /> le <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> 210`: �R. 0� b-l? SR# 03 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCRO/AC�HMENT DOC <br /> EHD 29-01 10/28/09 ���� PtM1T APP <br /> r: <br />