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3 ? L.d <br /> oP41•". SAN JOAQUIN COUNTY <br /> .tj�l ° 0 2013 <br /> a ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> �#.}600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephoner:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> q�f FpR� <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 /> Assessor's <br /> Well Location 7675 W.11th street Cross Street Poplar City Tracy CA Zip 95304 Parcel# 250-140-12 <br /> Property <br /> Owner Yvonne Miller Address PO BOX 366 City Tracy,CA Zip 95378 Phone# 209 835-3466 <br /> C-57 Contractor TEG-Northern Califomia Inc. Address 11350 Monier Park Place City Rancho Cordova Zip 95742 LIC# 706568 Phone <br /> Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Avenue City Modesto LIC#706568 Phone 209 579-2221 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> M0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑� *OTHER Thfeetempom,ysoil gas sampling points GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL —4.5 feet TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE O PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Bentonite <br /> MOTHER: Soil Gas Sampling Point ❑OTHER: APPROX.BORING DEPTH 5 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:tempo-,yprooes <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 prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations nd all applicable lifornia Laws. <br /> Signed Title/Company 131x'6y L k <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 74 /�j� I ' r�r St <br /> WORK PLAN DATED: M La rbti CZ12 13 <br /> APPLICATION ACCEPTED BY V I GIGS 0���� � DATE ISSUED N _P1?S 3 AREAI�7 <br /> GROUT INSPECTION BY ��jM1/ � � p �l�JgQae/ FINAL INSPECTION BY t U�it //jDATE <br /> DESTRUCTION INSPECTION BY y DATE <br /> COMMENTS/CONDITIONS: 1 /;41z 0,J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3 SO 5 x12s-'d 0 $'66' G/A S-1/3 SR# 00&1q5-,f <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN—P—ERIP777 ENCROACHMENT DOC <br /> EHD 29-05 Z1 10/28/09 J 7S, `V i0 3 'WELL PERMIT APP <br /> '"0 , 67I 4- 2SO.6 V 0V� ' <br /> —tah6t Vm (0/zc y��" }So.ot, <br />