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drop./1. SAN JOAQUIN COUNTY <br /> ' r ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> V600 East Main Street, Stockton, CA 95202-3029 Ejj *"T4GATN <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s' ov.or / <br /> S, to'A" , <br /> WELL PERMIT APPLICATION JAN 18 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appli S C ( <br /> an <br /> ES <br /> Joaquin County Development Title,chapter&1115.3 and the Standards of San Joaquin County Environmental Health Depa Assessors <br /> Well Location 425 Larch Rd, <br /> Cross Street Tracy Blvd. City Tracy Zip 95304 Parcel 21220008 <br /> PropertyOrange Zip 92867 Phone* (714)408-0418 <br /> Owner Fr f c Tran Dort INC Address 1049 N.Glassell St. City <br /> C-67 COntmetorTEG Northem CalifomiaAddmss 11350 Monier Park Place City Rancho Cordova,zip 95742 Lic# 706568 x-16 853.8010 <br /> V <br /> Consultant/Sub Cn <br /> Ami Adini&Assoc.Inc Address 4130 Cahu ng Blvd Ste 113 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: ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> M NEW WELIJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑OVER-BORE DIAMETER <br /> ❑SOIL BORING# ❑PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS <br /> ®-OTHER me, acro es V 1— V ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS. <br /> TYPE OF WELL tN4I6 t— TYPE— <br /> CONSTRUCTION SPECIFICATIONS <br /> &�TION <br /> ❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE � O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: U4' <br /> ❑EXTRACTION [I AIR HAMMERIDRIVEN CASINGTHICKNESS 1/16" TYPE OF CASING:0 STEEL PVC ® OTHERp tubing <br /> ❑VAPOR [I MUD ROTARY <br /> DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGEIOZONE M PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes IM No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Ce ent <br /> ISI OTHER:SOLI GaS Probe 0 OTHER: APPROX.BORING DEPTH 5.5 feet 0 BOLLTIEeD T FFF�IIC BOXXO 0 STIOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> COMMENTS: For add tionaldetaill;please see the <br /> Workol <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby beftlty that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rubs and <br /> SignedRegulation and aH Pp ble California law&. <br /> 1.-1 AMMLTitle/Company TEG Northern California <br /> PrintN "`� Date 01-13-2011 <br /> Print Name Larry Nfilrlw.AABA on 6ehey d TEG Northern Califomia <br /> ,{ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 25 LQ r LRA <br /> WORK PLAN DATED: S t f7/ o <br /> APPLICATION ACCEPTBY r DATE ISSUED / �- / AREA '�Il s <br /> ED q <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> S <br /> COMMENTSICONDITIONS: ri`t <br /> fl s - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 12 488 OZ) /74, 3 SR# 0061854 <br /> C-577_WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 0—ENCROACHMENT SDOC <br /> WELL PERMIT APP <br /> EHD 29-01 1W2a/09 <br />