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ROL <br /> PQutN to SAN .10AQUIN COUNTY JUL 16 <br /> N; -lEgWIRONMENTAL HEALTH DEPARTMLENRUNMENjHE/�j�,SITE <br /> ,. ACETO East Main Street, Stockton, CA 95202-302fEf�(!/jIT/� R��C;�e ttil_GATION <br /> �Qc1Fo�N�P pERIITlerheph�ane:(209)468-3454 Fax:(209)468-3433 Web:v✓ww.si4ov.or /q ehr t� UNIT IV <br /> WELL PERMIT APPLICATION ,/1_ <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ��' <br /> V iG <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ <br /> ed This application is made in compitanse withith S 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 Grant Line Road Cross Street Corral Hollow Road City Tracy Zip 95377 Parcel# <br /> Property <br /> Owner Citv of Tracy Address 333 Civic Center Plaza City Tracy Zip 95376 Phone#209.831.6400 <br /> C-57Contractor Cascade Drilling Address 3632 Omec Circle CityRancho CordovaZip 95742 Lic#C57 938110Phone <br /> Consultant/SubCntrARCADIS US,Inc. Address3240 El Camino Real,#20(CityIrvine Lic# Phone 714.730.9052 <br /> GIS Coordinates:X Y _ Township 2S Range 5E Section 20 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# � ®OVER-BORE DIAMETER <br /> ❑WELL# 0 PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS I <br /> 0 EXPLOSIVES DETONATING CARD <br /> COMMENTS:Properly destroy five GWM wells (MW-5, MW-6, MI-7, MW-8, MW-]2) and one GW extraction well (EX-6) . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE (\�` <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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,and all applicable California� Laws. <br /> Signed f�/— Title/Company Principal Engineer / ARCADIS U.S., Inc. I <br /> Print Name Allen C. Just, P.E. Date July 15, 2010 <br /> re DEPARTMENT USE ONLY f t ��401t6 i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED Ll ' 1 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY-- ATE / C> C <br /> COMMENTSICONDITIONS: 45 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE LPERMIT/SERVICE <br /> VOICE <br /> Ito a �� � Tl <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDOC <br /> EHD 29-01 10/28/09 1�*0 WELL PERMIT APP <br />