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San Joaquin County <br />Envi.nmental Health Department_ L__,_, Ili SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehg-,'L 1 2607 UNIT IV <br />NNAL Well Permit Application ENVIRUN,'','Eii <br />Pi_nM.1 T/ 3,ER, IES <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 />Assessors <br />WELL Location 355 Enterprise Place Cross Street Industrial way City Tracy Zip 95304 parcel# 212-210-08 <br />PROPERTY <br />Owner MARAAr�4MAHmoun Address 2300 S RESERVIOR City POMONA Zip91766 Phone# 209-830-7317 <br />C-57 Contractor Advanced GeoEnviron encal Address 837 Shaw Rd. City Stockton ip95215 LIC# 680227 Phone# 209-467-1006 <br />Consultant / Sub Cntr came As annva Address City Lic# Phone# <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />RSOILBORING# 31-6, V1-4 DOVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />N <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (d <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE -1. 25 ° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFC -TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 5 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FA/ / DEPTH IS 30') <br />n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type II <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH V=5' , B=10-30' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan I0�d egulationsl and all applicable California State Laws. <br />Signed x;?— Title/Company Vice President <br />Print Name Robert Marty Date n7 1 8/n7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 35-5 I: n �- ori st. Place 1 ra <br />WORK PLAN DATED: Al aNJ aa, -'2 D 0 7 <br />Application Accepted B,y'V 1 Csi'_11Y i a L. M e LGiY I /1 a % <br />�j Date Issued !/22 3 1 0!7 Area <br />/ <br />Grout Inspection By I') C.-fibY C i% 6 by,1Date P 'q -0 '7 Final Inspection By Y i Cie-, -A, iZt�Gi r&9-,, Date / 0 1 0 <br />Destruction Inspection By Date Sail a <br />• <br />COMMENTS / CONDITION <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />5 EC'D BY <br />DATE PERMIT / UEST # <br />INVOICE <br />3so <br />20S,o� <br />374.06 <br />�59 <br />�M <br />7- <br />R# I�J38C3 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ ncroac m nt doc_ <br />EHD 29-02-001 <br />6/22/04 <br />