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UPI• .IOAQUIN COUNTY w w F IL <br /> EDENVIRONMENTAL HEALTH DEPARTMENT 'SITE <br /> E600 East�Main Street.�Stockton, CA 95202-3029 MITIGATION <br /> %2D10 Telephone:(209)468-3449 Fax:(209)468-3433 Web WWw.sjgov.oM ehd UNIT IV <br /> �. ,, a <br /> ENV({�E N r�E4�T HEALTH WELL*"PERMIT APPLICATION , <br /> �'ERMIT(SERVICE3 ' k Q�1 <br /> I NON-REFUNDABLE PERMIT EXPIRES I YEAR FRAM DATE ISSUED <br /> t <br /> Application is hereby made to San Joaquin County for a permit lo'canstruc(and/or install the wort described. this application is made in compliance with San <br /> Joaquin County Development Tifie,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ; li' <br /> Wall Location 23fi0 East Street Cross Street ` Grant Line Road City Tracy,CA Zip 95376 Parcel Assess6r 23346"1 <br /> Property ' I& <br /> Owner John Pestana OTIP Trust Address P.D.Box 672 City Tracy,CA Zip 95336 Phone# 2pg.239-5= <br /> f C-67 Contractor Fisch Environmentat Address 3150 Johnson Ftoad City HVdesyiiie Zip 95547 Lic# C57-WB65 Phone <br />[ i j 707-76$-9800 <br /> I ConsultanVSub Cntr'Lee&Pierce,Inc. Address 135 South Fifth Avenue,Suite C CKy Oakdale,CA Lic* Phone 'o <br /> I GIS Coordinates:X Township 2 SouthRange 5 East Section 21A <br /> WORK TO BE PERFORMED: {, <br /> ©NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCIAHAND AUGER.OTHER') Q DESTRUCTION(CHOOSE TYPE BELO" <br /> El SOIL BORING# k ILPVER-BORE DIAMETER 4•(MW I.3);7(MW4I <br /> ❑WELL# • w !. Q PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS sex cep m <br /> COMMENTS: <br /> V, <br /> TYPE OF WELL INSTALLATION TYPE t CONSTRUCTION SPECIFICATIONS �I <br /> .k V <br /> M MONITORING ❑HOLLOW STEM ;DIA.OF BOREHOLE ❑MULTIPLE CASINGS©MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION 1' (� <br /> ❑AIR HAMMERlORIVEN t,CASING THICKNESS �I TYPE OF CASING:©STEEL ©PVC ❑ OTHER 1 n <br /> ❑VAPOR ❑MUD ROTARY 1#DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE��✓C <br /> 0 AIR SPARGEIOZONE [3 PUSH POiW'(GP OR CPT)I`x `=.;GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> [3 SOIL BORING ©HAND AUGER GROUT SPECIFICATIONS Neat Canxik Grout `\Aj <br /> ❑OTHER: 0 OTHER: r'. APPROX.BORING DEPTH 20 feet Fj ❑BOLTED TRAFFIC SOX ORI❑STOVE PIPE <br /> N - COWE)GCTOR CASING PROP (0 YES,its spedri=ons in comment sedw) <br /> COMMENTS:_-,-/1!vw 4: �O Q(,c,GG ! — _ 17 C1�-trQ.�*� <br /> 4j:! Ud i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS �' 1 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR iINSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinandes Rules and <br /> Regulations, ndpplicable California Laws. ^ <br /> I Sied `"`""'e--��" Tillenompany Vice Prasldent,Lee 8 Pierce,Inc. <br /> I <br /> Print Name John P.Lane,PG6795 Date © C b <br /> DEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY <br /> b DATEISSUED AREA 06 <br /> GROUT INSPECTION BY .FINAL INSPECTION ON BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDI TIONS: <br /> a^ F # <br /> ACCOUNTING ONLY: ALD# • FAC <br /> PE CODS I FEE INFO AMT REMITTED CHECK d RECV'D BYDATE PERMITISERVICE# INVOICE <br /> 0 ., S <br /> C-57 VNC -WAIVER C57 LETTER OF AUTHORIZATION TO;SIGN PE=RMIT ENCROACHMENT DOC <br /> EHE 2"I I I/SO7 _..•,. _ r ? .. Ew _ WELL PERMIT APP <br /> fILE COPT, <br />