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_ NOV 1 0 2006 <br />San Joaquin County <br />r IRUNMENT HM6*onmental Health Department <br />"• BAIT/SE%Cffit Weber Avenue, 3rd FloOT, Stockton, CA 95202 <br />(209) 408-3449 Fax: (209) 468-3433 Web:. www.sjgov,org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />NON.RISFUNDABLE PERMIT CKPIR1f -1 YEAR FROM DATE ISSUED <br />Appllcnlicn % hereby matle 10 Son Joaquin County for a pe ".It to conrmuK andMr install the worts dascribtd. This application in made In cornpilanve vAO San <br />Joaquin County Development Title. Chapter f�-1 116.3 and the Standards of San Joaquin County ErMronrrwntal Hoalth Depamnent. <br />Asaeeaor!} <br />3`/80 6�est Lingle load S Ahern Rd Tracy 95376 155 02-UU3 <br />WELL Lo7caYflon _Gros® Street City ZIP —_Parcatft --_-- <br />OwnarPROPt-Donald Sinclair 3780 West Linne Rcad Tracy 95376 ?.09) 933- 517 <br />owner_ — Address City Zlp Phoneik_ <br />Rancho Cordova TEG 1Q LISo Monier Park F1 Clty z1p95742 LI�70656A n (516) H=3-6010 <br />C-67 Contractor Addrea <br />Consulmnt/ Sub CntrGeological Technics Address 1101 7th Street —QW ModesCo Ucg Phorm# (209) S22- 1119 <br />018 Coordinates: X`_ , Y Township Range _Section_ <br />WORK TO BE PERFOIriMED: <br />p NEW WELL / SORINGt► (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTIIER") o OESTRUCTION (chaos® type below) <br />SOILBORINGS 5 (SG -1 thru SG -S) b aOVER-BORE. DIAMETER <br />VNELL # _ a PRESSURE GROUT <br />Q `Other _ GROUT SPECIFICATIONS <br />COMMENTS: <br />TYKE OF WELL INSTALLATION TYPE CONSTRUCTION SPECTICATN= <br />U MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE`_ p MULTIPLE CASINOS p MULTI-LEVFL WELL CASING DIA; <br />a EXTRACTION Q AIR HAMMER/MVEN CASINO THICKNESS__ TYPE OF CASING; U STEEL p FVC I7 OTHER: ___ <br />ll VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S-6 ' _ TREMIE TYPE TO BE USED: GAUGERS a HOSE <br />n AIR SPAPOE/ OZONE'PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes U No (NOTE: MAXIMUM FREE -FALL DE13TH 19 301) <br />H SOIL BORING Il IIAND AUGER GROUT- SPECIFICATIONS �� ��} 1 C e y" CCS <br />1] OTHEt2:p OTHER —_ APPROX. BORING DEPTH- BOLTED TRAFFIC BOX or A STO\rE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list apectlloadons In comnn&nt sadtor,, <br />C0biMENT9;_ See P=ached trap dated AugusC 1.6, 2006 for any additional information __ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />49 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />1 hereby Certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br />County Ordinances. Rules and Regulations, and all applicable California State Laws. <br />Sig edx1'�11 tt _—Title/Comparl TEG Northern California Snc <br />Print Name R@h^ a IS. W,'1�„�So�� Dpterl�.------- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 TV0 0PW z 120co 1 <br />WORK PLAN DATED: I�1Io6 <br />Application Accepted 8y 1 - Date lesued ! it 3,l0 Amami, Z t-1 <br />Gro4AInspeckion BDate t O T Final Inspection By��tncti�t- <br />Dastrwgxi Inspection By Date <br />C13IMINENTp! CONDITtONa; <br />ACCOUNTING ONLY.- AtOs--�- -- <br />FhGfb <br />PE CODES <br />FEE INFO AMOUNT RE.MIT71ED <br />CYBCK P RFCID HY <br />HATE PE IT71ERV=-PFCIJ"T 0 <br />INVoK, <br />`oo <br />o <br />SR# <br />a ,moo <br />C-57✓ _ WC__ -WAIVER_ C-57 Letter of Authorization -to sign permit__ Encroachment doc <br />EHD 29-02-001 <br />6,22,W <br />0 39'7d SOINHOSi 7VOI90�039 LZZb7Z55©� 9S 9T 913GJ�/TVTT <br />0 <br />r <br />G <br />