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0Aau'" San Joaquin County <br />/ Environmental Health Department SITE <br />7-j <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />\'t (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />Assessors <br />WELL Location Central Avenue cross Street Sixth Street city Tracy zip 95376 Parcel#_ 235_150-09 <br />PROPERTY <br />Owner Union Pacific Railroad CO. Address 1400 Doualas Street City_ Omaha. NE Zip 68179 Phone# 402-544-8600 <br />C-57 Contractor Address Cit; Zip '_ic# Phone# <br />Gregg n i u 950 Howe Road Martinez 94553 6567 925-313-580U-- <br />Consultant <br />25-313-5 00Consultant / Sub Cntr Geocon Consultants, Inc. Address3160 Gold Valley Drive, #800CityRancho Cordova Lic# Phone# 916-852-9118 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />[x] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />[X] SOIL BORING # 8 Geoorobe. 6 CPT 0 OVER -BORE. DIAMETER <br />[] WELL # [] PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: 1 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />AMOUNT REMITTED <br />[] MONITORING <br />[] HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />PER EQUEST # <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />tr <br />0 VAPOR <br />[] MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />C' <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />Un <br />[] OTHER: <br />[] OTHER <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or [] 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 prepare his application and that the work will be done in accordance with San Joaquin <br />Cou y-Or'nances, Rul and �g ations, and all applicable California State Laws. <br />Signed ;e Title/Company _ Geocon Consultants, Inc; <br />Print Narrle//James F. Brake Date 7 <br />�� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRE S: ll to <br />WORK PLAN DATED: 16 6-7'OT <br />Application Accepted By Date Issued / Area <br />Grout Inspection By DateC Final Inspection By Date <br />Destruction Inspection B Date <br />COMMENTS / CONDITIONS: eq <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER EQUEST # <br />INVOICE <br />D <br />I <br />'a - I <br />41L( b'1 <br />*k� t - <br />a- <br />S R# <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ oc_ <br />EHD 29-02-001 <br />6/22/04 <br />