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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />ORIGINAL <br />u U E�V_ITE <br />MrrIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd A,.PR — 2 ?007UNIT IV <br />`�11 Well Permit Application E <br />PP NVII�ONI�;�:NT HEALTH ON <br />M T/ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERSER RICES <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 />City <br />2360 East Street Grant Line Rd., Tracy 95376 Assessors <br />WELL Location Cross Street Zip Parcel# <br />PROPERTY John Pestana <br />Owner 4TIP Trust Address PO Box 672 City Manteca Zip 95336 Phone# 209-239-5033 <br />Valley <br />C-57 Contractor Fisch Drilling Address 399 Sheri's Place City Sprinqs Zip 95252Lic#683865 Phone# 209-772-3570 <br />Ground Zero <br />Consultant/ Sub Cntr Analvsis, Inc. Address 1714 Main Street City Escalon Lic# Phone#209-838-9888 <br />GIS Coordinates: X31-:10 Y ~IZI • q2-0Township2S Range 5E Section 21A <br />WORK TO BE PERFORMED: <br />ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # SB17 0 OVER -BORE. DIAMETER <br />WELL # MW4 0 PRESSURE GROUT <br />*Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />jj,MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />'IN <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'HOLLOW STEM DIA. OF BOREHOLE 8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING: 0 STEEL APVC 0 OTHER: O <br />0 MUD ROTARY DEPTH OF GROUT SEA' 2 TREMIE TYPE TO BE USED AUGERS HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 20 ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Boring SB17 will be advanced to 10' below grade, and will be grouted upon completion. <br />0 Q <br />0 Yes �No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Neat Cement Grout <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 Ordinances, Rules an egula ions, and all applicable California State Laws. <br />Signed x Title/Company PG SO 23 <br />Print Name 6x Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Ndh-� 35'°3 <br />Final Inspection By --- = =-=-- <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT <br />ST # INVOICE <br />C-57 V WC_ -WAIVER_ C-57 Letter of Authorization to sign permit V*" Encroachment doc.0 <br />EHD 29-02-001 <br />6/22/04 <br />.p <br />