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WELL PERMIT APPLICATION FuRM <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />WELL Location 612 W. 11`" St. Cross Street Roosevelt St. City Tracy Zip 95376 _Parcel# <br />PROPERTY Owner Souza Realty & Development Address 105 E. 10`h St. City Tracy Zip 95376 Phone# 209-835-8330 <br />C-57 Contractor V&W Drilling Address 100 Fifth Street City Isleton Zip95641 Lic# 720904 Phone# 916-777-4100 <br />Consultant / Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: X Y Township 2 S Range 5 E Section 20/21/28/29 <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH <br />0 SOIL BORING # <br />HAND -AUGER, OTHER') <br />[X] DESTRUCTION (choose type below) IM <br />[x] OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: Destroying existing 2"dia. monitoring wells MW1, MW2, and MW3 by over drilling and grouting. n� <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[X] MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />*COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: rt <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE s <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 County <br />Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x �, Title/Company CA Registered Geologist¢795 round Zero Analysis, Inc. <br />Print <br />N <br />)EPARTMENT USE ONI <br />SITE MAP IN UNIT IV FILE, ADDRESS: �o 12 vvesf IIS` stree-f - Tra e�v . (fA� 9537 L <br />WORK PLAN DATED: A u A 1 s -f 18 Z D 0 4 <br />Application Accepted By V I c -+t) Y L • hlC Date IssuedA[i a ust 2S, Zoo4 Area /4S9 <br />�/ <br />Grout Inspection By 1; e+6 jrV.,,,4-.,,:A <br />, A Date 7 A Final Inspection By Date <br />Destruction Inspection By ►/ j ,. 4-n r: A L. MA 5 ri,9ea ate 91 7 /0 5l <br />COMMENTS / CONDITIONS: � C S�Y Li G�I� <br />-3 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ ERVICEREQUEST # <br />INVOICE <br />3502 <br />Go. oo <br />GO. Oo <br />SR# 00 393 85 <br />C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit_ 1/25/02 <br />