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SAN 1OAOUIN Environmental Health Department <br /> - - <br /> - -CUUNTY - <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT MPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953J697 For INSPECTIONS <br /> This application Is made incompliance on Is wi h San Joaquin made to San oCouinty Devlelopme for a nt Title,Chapteit to r D-11ct 15.3.a Install <br /> the San Joaquin County Well Standards. <br /> Job Address valpico Road Cltylstatelzip Tracy, CA Phone N/A <br /> Cross Street Wolkinsnn Way AFN 240-090-930 <br /> Property OwnaP City of Tracy Phone Emal:00ke@d1y*&Cy'.Org <br /> Address 333 Civic Center Plaza —City/State/Zip Trac /CA/95376 <br /> C47 Contractor v&vv Drilling, Inc. Lic4inse# 720904 3 24 Phone 209-469-7700 <br /> Address 113.5 BlaCKnUrst Drive Citylstatelzip Galt/CA/ 5632 <br /> ConsultanuSubContractor Universal Engineering Sciencesucense# Phone 916-372-1434 <br /> Adaresa 3050 Industrial Boulevard ciryistaterzip West Sacramento/CA/95691 <br /> CONSTRUCTION WORK TO BE PERFORMED,'Note., ORsile BoringsNYells Require Access Agreements or Encroachment Permits <br /> TYPEOFWELUBORINO NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING OEM ❑BOLTEDTRAFFIC 80X ❑STOVE PPE <br /> O EXTRACTION(VoWWsw) _0 HAMMERDPoVEN Dw OF BOREHOLE ❑BOLTEDTRIPLE AFICBSINGS OMULTFLE 133TOV EL WELL CASING qA <br /> ❑ SOILBONNG ROBE _O MUD ROTARY CASINGTHICKNESS 9YPEOFCASNG: OGTEEL OPVC O OTHER <br /> ❑ SOIL BORING _O PUSH POINT(GP/CPT) CONWCTOR CASING ❑Yes 0N6 81dnU Da Cm4 Dla ca$Lv Depae <br /> ❑ INJECTION wsme.Drew _O HANDAUGER GROUT SEAL DEPTH TREMIETYPEY08E USED ❑AUGERS 0I SE ❑PIPE <br /> 11 OTHER ❑ OTHER GROUT SEALPUMPED7 ❑Yes ONO (Na :Marimm Freest Deph is 70 FQ <br /> WE W SOIL BORING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHE KALL THAT APPLY) <br /> N WELLS TO BE DESTROYED Three ❑OVER•BORE DIAMETER of inches to deph of feel <br /> WELL IDs MW1 MW ®PRESSURE GRIXR Todeptl)ol 32, (eat bebw sudace SP o .),� �/.ry.M <br /> GROUTSTREE nee cemen ❑EXPLOSNES From to (eel hdmvsudaca � <br /> COMIETYPE TO SE USED AUGERSIIIII,,,��C HOSE ®1P'IPE MUSHROOM CAP ❑p13�feeff[belmv surface or feet blel,ow surface if>J set �" '"•� <br /> COMMENTS: PYDJ <br /> G_l�/ I�LH- 5»+, . L ra•�d.ro s �t� n»r�-Maas Vabo12 +�rtf/Y r1o�`ur ate. <br /> I hereby cerllty ihatla authorizedto mplete mie application antl that the ork Wlll bedone In accordance with <br /> man Joaquin County Ordinance Codes and Standards;and all other appilcabloCllalifomlalaws. <br /> Signed� �c�� —3��� TillelCompanY L(. LFIA�j yL¢X�Vll�tGy S116,L(�eJ--- <br /> P(Im Name ,-,i-at,T ts� Dale <br /> DEP RTMENTUSEONLY n �7 Application Accepled By: Date Issued: <br /> Grout Inspection By <br /> Destruction Inspection By/Dates: - 7 <br /> EMCM11 B to Information <br /> FAName a 'r IARJ AAdrress k1pl,ca FM 106 zi& PfUt <br /> Do � <br /> FA PE 2. 1WP ReMeNed By mo11 w. Work Plan Dale f {1� <br /> ❑C-57 C57AOBnma6wR,OUw WSlyn/PwM OworketsCOmp 0W0kers Ca9Waiw OEntla&*MlPmal ❑Aoamftgre_l ❑LeWAgrgApprova MFR \."�q I �1 1 <br /> COMMENTSIC DITIONS: VJP_", %Y�L4A( w'?00 L+Zq0 S , W t4 d ) <br /> WP TYPE PE SC FEE INFO AM,TyREMITTED CHECK# 'RECVD BY DATE WELL PERMIT# y INVOICES <br /> Permit ZQQ 31 162, r 't g6 C It7 �.'(' 1 li : <br /> 1868 E. Hazellon Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464.0138 1 www.sjcehd.com <br /> EHO"AH 04 M-23 Sile Mitlpaeon Wes Pann1ANNKaean <br /> ce IfiU °� 0 `+ 6 � 8 <br />