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San Joaquin County ORIG A L <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 952GATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orAWCENEMNIT IV <br />Well Permit Application SEP 1 4 2007 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />AID# <br />RRn t�1T <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ h1� �e5librl��n compliance with San <br />R <br />PE CODES <br />Joaquin ou,nty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmen /Sa@S <br />AMOUNT REMITTED <br />rb/ > i� Assessors <br />/ Tracy 95376 Parcel# p <br />WELL � W Cross Street Zip 1\�i1 <br />REC'D BY <br />cation � < - - _.ty <br />INVOICE <br />PROPERTY <br />Owner City of Tracy AddreSS 333 Civic Center Plaza City Tracy Zip 95376 Phone# (209) 831-6800 <br />C-57 Contractor AGE/ Envi roprobe Address 837 Shaw Road City Stockton Zip CA Lic# 680227 Phone# (209) 467-1006 <br />SR r`1 <br />Consultant/ Sub CntrAdvanced GeoEnvironmentalAddreSS 837 Shaw Road City Stockton Lic# 680227 Phone# (209)467-1006 <br />GIS Coordinates: X Y -124.q2(P-7- Township Range Section <br />WORK TO BE PERFORMED: <br />b NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) D DESTRUCTION (choose type below) <br />O SOIL BORING # 6 D OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />D *Other GROUT SPECIFICATIONS <br />COMMENTS:six off-site soil borings, 4 in middle of Adams St and 2 along west sidewalk (encroachment permit attached) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />f a__D <br />D MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.25110 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: _n/a- <br />aEXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS n/a TYPE OF CASING: D STEEL 0 PVC D OTHER: _n/a <br />D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 251 TREMIE TYPE TO BE USED: 0 AUGERS D HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes ff No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />t SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS type I/II Portland cement <br />D OTHER:_0 OTHER APPROX. BORING DEPTH 25' D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED n/a (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 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 W,.I." and itegulations, and all applicable California State Laws. <br />Signed x Title/Company Vice President <br />Print Name Roberty Marty Date 9-14-07 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: �36 le�� <br />17-6 ""'` Area 64� <br />Application Accepted By Date Issued <br />Grout Inspection By ate Final Inspection B Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER QUEST # <br />INVOICE <br />SR r`1 <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit ncrroac enT oc <br />EHD 29-02-001 C. Pi 7* ?ZO <br />6/22/04 <br />