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ORIGINAL <br />San Joaquin County <br />Environmental Health Departme C <br />5 jjWE �)� SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9 E I�u ITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sj'gov.org/ehd UNIT IV <br />2 2007 <br />�� �.,� - <br />{7��.�� .fWell Permit Application A?f� <br />((S�III RO(` N?EL i HEAL! H4i"11V <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS�U �? Mi-r''�RV��ES <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 />ZGTracy Line Rd 95376 Assessors <br />WELL Location _ _ _---� IZ 7 T S l Cross Street City y Zip Parcel#33-460-02 <br />PROPERTY FJ Leonardo Castro <br />Owner & Son, Inc. Address PO Box 20568 City Valley Zip 94546 Phone# 510-886-2040 <br />Valley <br />C-57 Contractor Fisch Drilling Address 399 Sheri 's Place City Springs Zip 95252 Lid* 683865Phone# 209-772-3570 <br />Ground Zero <br />Consultant/ Sub Cntr Analysis, Inc. Address 1714 Main Street CityEscalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: X ?A. 16q , Y —1 21. 42CJ , Township 2S Range 5E Section 21A <br />WORK TO BE PERFORMED: <br />rEW WELL / BORING <br />-SOIL BORING #_ <br />0 WELL # <br />0 *Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />SB24 <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: Boring located in the parking lot of the neighboring shopping center <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.75"� MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ______ <br />0 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 10' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 'PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 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 10' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Ordinances, Rules ¢ Re lati s and all applicable California State Law <br />Signed x ' / Title/Company /96 s0,3 GROt lvi:) ZZ0D /-VA-e-YS%S <br />Print Name 6s?aGL,/zY P - 57;�+iV c-- Date 3 2 7 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Z 3 6 O (5a" <br />Date <br />Date <br />I Inspection By <br />-<-->'7 Area 6 (0� T' <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P RVI C ST # <br />INVOICE <br />3-50 �pkb <br />37�}•� <br />o i 6 S <br />3.2.9 SRLA <br />C-57 V WC= WAIVER_ C-57 Letter of Authorization to sign permit_Encrpowh ent doc_ <br />EHD 29-02-001 ax ­r_6 /, Q.�iG�e rA_ C <br />6/22/04 d 0 <br />