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Eio1m 1 , ^t, E'3T' LHEALTH • <br />Sq QUIU1 �VELL PERMIT APPLICATION F RM <br />304 WEBER AVE Sac <br />STC?ON CA 95202-2708 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />90 ..- (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 612 West 11" Street Cross Street Roosevelt City Tracy Zip 95376 Parcel# <br />3 y r►'', 0 <br />PROPERTY Owner Souza II LLC Address 105 East 10`" Street City Tracy Zip 95376 Phone# 209-835-830 2`5' <br />C-57 Contractor Vironex Address 2110 Adams Avenue City San Leandro Zip 94557 Lic# 705927 Phone# 510-568-7676 <br />Consultant / Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# <br />GIS Coordinates: X , Y <br />Township Range <br />WORK TO BE PERFORMED: <br />[X] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />[X] SOIL BORING # SB1 <br />0 WELL # <br />*Other: <br />COMMENTS: <br />Grout Specifications: <br />Phone# 209-838-9888 <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT r; <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1 '/z " MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OOTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Up to surface grade TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE [X] PUSH POINT GROUT SEAL PUMPED: 0 Yes [X] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[X] SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat cement/bentonite <br />0 OTHER:_G OTHER APPROX. BORING DEPTH 35 ft 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: A tremmie pipe will be used to place grout seal to surface <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances Rules and <br />�� Regulations, and all applicable California State Laws. <br />Signed x ��' ` V "���� Title/Company CA Registered Geologst 6795 Ground Zero Analysis, Inc. <br />— / ..: i <br />Print Name John P. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: i� 12 West 1 I+- - Stre e-" <br />WORK PLAN DATED: do n U a r u 22 , Z 0 0 9- <br />Application Accepted By L Date Issued M tj r S - z Area 145-9 <br />Grout Inspection By Date 8, LO 7 Final Inspection By %�to G iI <br />Destruction Inspection Bya Date <br />A <br />COMMENTS / CONDITIONS: aiyq`r p rn A % O f O Y1 P so; I b n ,,.n.4 , S 13 I . <br />1� <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ SERV4CERQQUEST# <br />INVOICE <br />350 ► <br />8q.00 <br />89.oa <br />013314 <br />am 003711 5 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ 1/25/02 <br />