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—San Joaquin County " <br /> LE COPY <br /> N Environmental Health Department <br /> /40 <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 elllil/ NUCATION <br /> 209 468-3449 Fax: 209 468-3433 Web: www.s ov.or /ehd,p ,r,a7 <br /> q ( ) ( ) �g g EjT�V %�T�F NIT IV <br /> LIFOR Well Permit Application �A <br /> ss <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 /> 104 West Bever) Place VMS-046 Holly pr;vL Trac 95376 Assessors <br /> 233-153-13 <br /> WELL Location y Cross Street � ' City y Zip Parcel# <br /> PROPFA7U(ey Skelton 104 West Beverly Place Tracy 95376 <br /> Owner Address City Zip Phone# 1-209-832-7602 <br /> C-57Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94533LiC#485165Phone# 1-925-313-5800 <br /> Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd City Stockton Lic# eso227 Phone# (209)467-1006 <br /> GIS Coordinates:X3'774 09GSS'13,Y-/z1.YzL995�3 318 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> •3 ff SOIL BORING# ATB-1 & ATB-2, B-27 Q OVER-BORE. DIAMETER <br /> l U WELL# MW-8 Q PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS: Please refer to SJCEHD approval letters dated 03 March and 11 May 2010. O <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 211 <br /> * <br /> MONITORING M HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 0.15411 TYPE OF CASING: Q STEEL ItPVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 12' and 25'TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> Q AIR SPARGE/OZONE 8 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes 8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Portland Type II �I <br /> w <br /> Q OTHER: 12 and 20 Q OTHER APPROX.BORING DEPTH �BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (if YES,list specifications in comment section) <br /> COMMENTSZnstallation of one (1) 25' monitoring well and boring advancement of one 12 and two 25-foot borings <br /> *Proposed well to be bored with 8" hollow stem augers and boring to be advanced with <br /> 1.25" ush oint rods. One 25-foot boring to be continuous) cored to verif litholo on1 . <br /> NOTE: OFFilTE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PE9MITS�. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. �S <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 and Regulations, and all applicable California State Laws. <br /> Signed x / Title/Company Staff Geologist/ AGE <br /> Print Name Daniel Villanueva Date 08/09/2010 <br /> DEPARTMENT USE ONLY i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: j D 4 �A)0_5f RelVe-,'I L4 <br /> WORK PLAN DATED`: i-fZ/�D,Z/C)gL 6�/(J8 Z/� , arra 2Z <br /> Application Accepted By_Vi/1 e tb rDate Issued 8-13 -1 L0 Area <br /> Grout Inspection By Vi city i 0 mi:&ritIA14 Date Final Inspection By YI L-366 ml C'dr+?ZW-4 Date -/7-/ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 15,01 122.X t 3IS�3 _r <br /> sor 34'si00 , 1�� _ 3- G 3R# 07 r� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permitn )0 tfteAIol3 <br /> EHD 29-02-001 R!� <br /> 6/22/04 <br />