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San County Joaquin CORIGINAL <br />9 Y <br />Environmental Health Department a I;__ SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9520 L� ICEU \` illt`FiGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />1741PTI-Ty Well Permit Application APR - 2 2007 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEI%VR0Ni41LNT HEALTH OF. 001 - <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. J�ia7ii�[�in compliance with San <br />Joaquin County DOcernfeFr:6 <br />pmt Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />2-3 south sides + Assessors i� <br />�O of Grant Line Road Trac 95376 RWELL LocationCross Street East Street City Y Zip Parcel# <br />PROPERTY City of Tracy <br />Owner Public Works Dept. Address 520 Tracy Blvd. City Tracy Zip 95376 Phone# 209-831-4420 <br />Valley <br />C-57 Contractor Fisch Drilling Address 399 Sheri's Place City Springs Zip 95252 Lic# 683865Phone# 209-772-3570 <br />Ground Zero <br />Consultant/ Sub Cnttrr-Analysis, Inc. Address1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: X ✓4• Y —�2� * * Township 2S Range 5E Section 21A <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />FEE INFO AMOUNT REMITTED <br />OSOILBORING# SB18, SB19, SB20, SB21, S322, SB23 DOVER -BORE. DIAMETER <br />REC'D BY <br />.WELL # MWS 0 PRESSURE GROUT <br />INVOICE <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: _ <br />ca En <br />" <br />q. 2. (jL <br />N <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 'HOLLOW STEM DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _2" <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING: 0 STEEL ,PVC 0 OTHER: <br />O <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 21 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE FUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes -J�No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 20' (MW5) BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Soil borings will be advanced to 10' below grade, and will be grouted upon completion <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, Rulesaryl Re and all applicable California State Law . <br />�� Title/Company �os623 6F°t�"'D <br />Signed x� <br />Print Name 6'REGQRY Sr�4h�Z Date 3 'Z ( D7 <br />7/D <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 23%o Fd/Z�C' LOP NE)N—D <br />WORK PLAN DATED: O <br />Date Issued ` 5' 0 Area <br />Application Accepted By <br />Grout Inspection By to Final Inspection By 3.20 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P EQUEST # <br />INVOICE <br />g <br />ca En <br />" <br />q. 2. (jL <br />C-57 - WC %,/ -WAIVER_ C-57 Letter of Authorization to sign permit ✓Encroac me­FiTgocZ <br />EHD 29-02-001 0 ` 0 ?• ,�92► <br />6/22/04 <br />