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WELL•PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(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 In enter divide north of 612 West 11 `h Street site Cross Street Roosevelt City Tracy Zip 95376 Parcel# <br />PROPERTY Owner City of Tracy Address 520 Tracy Blvd. City Tracy Zip 95376 Phone# 209-83PP 3I 1 �� <br />qvt <br />.20R-831 -444 <br />C-57 Contractor Vironex Address 2110 Adams Avenue City San Leandro Zip 94557 Lic# 705927 Phone# 209-831-4448 <br />Consultant / Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: <br />A <br />Township Ran <br />WORK TO BE PERFORMED: <br />[X] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />[X] SOIL BORING # SB2 drilled to 25 ft <br />0 WELL # <br />*Other: <br />COMMENTS: <br />Grout S <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1 'h " MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: 1 <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 <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 25 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 grade <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 />I 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 Regulations, and all applicable California State Laws. <br />Signed x_ C— Title/Company CA Registered Geologst 6795 Ground Zero Analysis, Inc. <br />Print Name John P. Lane DateG' �/IL /�-( <br />DEPARTMENT USE ONLY <br />tk <br />SITE MAP IN UNIT IV FILE, ADDRESS:N6 G 12 West 1 I th St ree�" j i rt -f tie e2 �P.•- GI i v_ <br />WORK PLAN DATED: J 22 <br />Application Accepted By + Date Issued _ Z Area_/ <br />Grout Inspection By ate l G 0 ' <br />Final Inspection By ate G 0 � <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: La 5 o; 2.. I n r e- G[yrin✓d; /;d -- <br />ACCOUNTING <br />ic1-- <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICER EST # <br />INVOICE <br />350 <br />99. 0-0 <br />9 9. o <br />013314 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per641=n aad mPnt 4e--' 1/25/02 <br />