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SAN JOAQUIN COUNTY * FILE COPY <br /> 2 " ` ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> w ` 600 East Main Street, Stockton, CA <br /> c P 95202-302a WT1GAT N <br /> Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.s ov.or <br /> / yn irNI <br /> �IFORe� <br /> WELL PERMIT APPLICATION JAN 18 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> FF <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicAR��c��T `n"nSwWan <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depart A55/SERVICES <br /> Well Location 425 Larch Rd, Cross Street Tracy Blvd. City Tracy Zip 95304 Parcel#21220008 <br /> Property <br /> Owner Frontier Transport,INC Address 1049 N.Glassell SL City Orange Zip 92867 Phone# (714)40 - <br /> C-57 COntmctO,TEG Northem Califomiagddress 11350 Monier Park Place City Rancho Cordova,Zip 95742 Lic# 706568 Phone <br /> (16.853.8010 <br /> ConsultanVSub Cntr Ami Adini&Assoc.Inc.Address 4130 Cahuenea Blvd.,Ste 1 I l City Los Angeles Lic# 587540 Phone 818.824.8102 <br /> GIS Coordinates:X <br /> 6292158.61' y 2102640.76' Township N/A Range N/A Section N/A <br /> (Rancho el Pescadero) <br /> WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTROVER-UCTION <br /> ORE )) <br /> DIAMETER TYPE BELOW <br /> E]SOIL BORING# ElPRESSURE GROUT <br /> El WELL# GROUT SPECIFICATIONS <br /> ®`OTHER Three 011 Gas Probes (SV 1—SV3) ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> F1 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.5" <br /> ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: 1�4�� <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 1/16" TYPE OF CASING:Q STEEL ❑PVC IN OTHER plylubing <br /> ❑VAPOR Cl MUD ROTARY DEPTH OF GROUT SEAL N/`4 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE M PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ®No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> M OTHER:Soil Gas Probe❑OTHER: APPROX.BORING DEPTH 5.5 feet ❑dB BOLTED <br /> eaAFFI nsin BOX <br /> XmORt O,STOVE PIPE <br /> CONDUCTORCASINGPROPOSED ( P <br /> COMMENTS: For additional details please see the enclosed Workplan <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 /> Regulation as d all cable California Laws. <br /> Signed <br /> Title/Company TEG Northern California <br /> Print Name <br /> Larry Witwer,AABA on behalf of TEG Northern California Date 01-13-2011 <br /> ,^r [ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 25 La ��"` R"` <br /> WORK PLAN DATED: U U S t () I D _!s <br /> APPLICATION ACCEPTED BAY/ i r DATE ISSUED_/ 2-9 / AREA/4S <br /> GROUT INSPECTION BY V i P71 b ri A, rnb trn _ FINAL INSPECTION BY DATES <br /> DESTRUCTION INSPECTION BY 11 oo DATE 11 <br /> COMMENTS/CONDITIONS: SyL I I Cf T erK O T J C,C/S ,�YDYJ E'.S Sri- ! -fll ro u0 S✓- 3 <br /> ACCOUNTING ONLY: 7AMTREMIT7TED <br /> FAC# <br /> PE CODES FEE INFO Tj <br /> # RECV'D BY DATE PERMITISERVICE# INVOICEo000 4, 3 l as-yl SR# 001,185'( <br /> 3sd3 �4G-Do <br /> C-57 WC _ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> JlD -2SZ WELL PERMIT APP <br /> EHD 29-01 10/28/09 <br />