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ORIGINAL <br />�opQ�t ,tea San Joaquin County <br />Environmental Health Department SITE <br />" { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />C� • �P <br />gc,FOR� Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made t0 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 />WELL Location 95 11TH STREET Cross Street ADAMS TRACY 95376 AssessorsCity Zip Parcel# 233-130-27 <br />PROPERTY <br />Owner JOSEPH PANETTA Address 95 11TH STREET City TRACY Zip 95206 phone# (209) 467-1006 <br />C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# 656407Phone#(925) 313-5800 <br />Consultant /SubAdvanced Geo'EEnvironmentCfldress 837 SHAW ROAD CitySTOCKTON Lic# 680227 Phone#(209) 467-1006 <br />GIS Coordinates: X 3-7' v Y—I 21 - Idd2 Township Range Section <br />WORK TO BE PERFORMED: <br />x)TNEW WELL/ BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />x)gWELL# MW -12 AND MW -13 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS:-�� on-site monitoring wells located approx. 15' from the buildings north wall. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />xx:8 MONITORING xxEF HOLLOW STEM DIA. OF BOREHOLE 8 . 25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ---- <br />G EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: `'AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II PORTLAND CEMENT <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 22' AND 35' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: MW -12 (22') AND MW -13 (35') <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 Ord' nces, Rul Regulations, and all applicable California t/te Laws. sy,g�F��vrS7�' <br />Signed x �. Title/Company <br />Print Name i'IQ (GL rr zkt— _ _ Date �02 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: L!/• l <br />WORK PLAN DATED: 300 0 <br />Application Accepted By Date Issued_ <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS/CON <br />/vans b //' P <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER ST # <br />INVOICE <br />moo, <br />i9 <br />0^3 of. <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit n oc <br />EHD29-02-001 WEB <br />9/11/2007 <br />