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Ur <br />q <br />- , ca <br />W <br />ORIGINAL <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 yIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehcOAR 1 9 <br />2 <br />008 UNIT IV <br />. qC �oP <br />Well Permit Application ENVIRONMENT HEALTH AAAA) 11 E 1q <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDpEr 1T,1SFRVIc,FSi <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mane n compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />''//// J / Assessors 1, �� <br />WELL Location 9� !�/• /! - Cross StreetA-44W ST City TRACY Zip 95376 Parcel# ba <br />PROPERT�ITY OF TRACY 95 11th Street <br />Owner Address City TRACY Zip 95376 phone# (209) 467-1006 <br />C-57 Contractor GREGG DRILLING Address 950 HOWE ROAD City MARTINEZ Zip 94SS3Li 656407 Phone#(925) 313-5800 <br />ADVANCED GEOENVIRONMENTAL 837 SHAW ROAD STOCKTON 680227 (209) 467-1006 <br />Consultant / Sub Cntr Address City Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />PE CODS <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />xjyNEW WELL/ BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />REC'D BY <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />INVOICE <br />X? WELL # MW -11 and MW -14 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />/14 CA&AA19 <br />COMMENTS: Two off-site monitoring wells along east and west shoulder on Adams Street. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />r -- <br />x.UMONITORING X)OCHOLLOW STEM DIA. OF BOREHOLE8.25" <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Xff PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .7 L LV TREMIE TYPE TO BE USED: GAUGERS a HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II PORTLAND CEMENT <br />y` ' <br />p OTHER: 0 OTHER APPROX. BORING DEPTH 22' AND 35' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />C <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: MW -14(35') and MW -11 (221) <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 Ordina ces, Rules an Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name %'1(it rrGLNZt —Date j7-0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectic <br />COMMENTS / CONDITIONS: <br />Date <br />UMENT USE ONLY <br />PS u/, // b`" <br />v'�.Jy 1):7- <br />Inspection <br />AlbAi -.b <br />M <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODS <br />FEE I O <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DAT PERMIT / S UEST # <br />INVOICE <br />/14 CA&AA19 <br />b , SR;DOS <br />C 7A/ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001 WEB9/11/2007 <br />