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EDSAN JOAQUIN COON D <br /> ENVIRONMENTAL HEALTH DEA NT SITE <br /> 600 East Main Street, Stockton, CA 952081922 4 2009 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sM1 1ov.or ehd �I UNIT IV <br /> i'atl'a�' %N,1yl <br /> WELL PERMIT APPLICA %;ig'RVIC_ <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 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 /> Assessor's <br /> Well Location 3940 Nath Trary Blvd Cross Street WLaren Rd City Tracy,CA _ Zip 95304-1516 Parcel#212-0aa00,t <br /> Property <br /> Owner cl,..ryn..a o.ededwe Address 3940N0MTrecYSivd City Tr ,CA Zip 953041516 Phone# <br /> C-67 Contractor Vimnex Address 5292 Pechem stud City Padh ci CA Zip 94553 Lic# 705927 Phone <br /> ConsuhanVSub Crdr ATCAfeedill Address 1117 two Palm Ave City Modesto,CA Lic# Phone(209)579-2221 <br /> GIS Coordinates:X 37.465741"N ,y 121-263.86" ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 9 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> i]SOIL BORING# set,sm,sm ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:See Sail and Groundwater Investigation Workplan,November 16.2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN 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)GP GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING OHAND AUGER faro deermrwe teat GROUT SPECIFICATIONS Neat Cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 12 to 15 ret bps ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOGED (9YES,list apedficatims in comment section) <br /> COMMENTS:Theenhrea*11dln w.h dnnnc nunan.rom.ncp.l^'aay oro eenmn tn­,.n..__—__--_ - - - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby c rtify that I have pared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio s, all a pli ablelriforq Laws. <br /> Signed (.Vl(IL,.-f' _Title/Company "imnex Environmental Rdd Sercicos <br /> Print Name MI�H fl;E'L 11• SoNKE' ___-------_ Date <br /> I' _ /DEPARTMENT USE ONLY C /(� �7 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 35 r� Nu � -tifi A/L_tr �/' 54.& <br /> � <br /> `f/ /Q <br /> 73 J <br /> WORK PLAN DATED: 200 <br /> APPLICATION ACCEPTED BY DATE ISSUED WZY/05 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY � DATE <br /> COMMENTSICONDITIONS: /?I" <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMYTTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 8`f bS ii 2 o sR#ovSa'� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERIPT ENCROACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT APP <br /> 3.5'30 <br />