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�4PE • SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> � SITE <br /> ! :,1V. 600 East Main Street, Stockton, CA 95202- ITIGATION <br /> tt Telephone:(209)468-3454 Fax:(209)468-3433 We GrSAVE�IJNIT IV <br /> a• ..:-: <br /> WELL PERMIT APPLICATION MAR tl ,y <br /> tt zol� <br /> p NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I[ Application is hereby made to San Joaquin County for a permit to construct and/or Install the work descrlbEd' nrs-ep�tl Frp�I `yompliance with San <br /> Joaquin County Development Tltle,chapter 9-1115.3 and the Standards of San Joaquin County EnvironmentIG11W,"�' vrl. c I n <br /> 523 Larch Road Tracy Blvd. rtsrcel# s <br /> Well Location Cross Street City Tracy Zip 95304 parcel# 21220005 <br /> Property BC Products Rental Pro LLC <br /> Owner P' Address 523 Larch Road City Tracy Zip95304 phone# <br /> G)" 4 Dr, (5eX)gn-G8 f9 <br /> C-57 Contractor -AQ -I I'mal Address x724 WOIn Uf Ave. CityS�nal N;ll AZip!?n Llc# /(S Phone-2, <br /> 0 <br /> ConsultanVSub Cntr AI Ach&Awocietes,Inc. Address 4130 Cahuenga Blvd.,Suite 113ly Llc# Phone Los Angeles 587540 818-824-8102 <br /> I <br /> GIS Coordinates:X 6291864.61' y 2102600.76 Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW: - <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# MWZ [I PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> KI MONITORING ®HOLLOW STEM DIA OF BOREHOLE 8" EI MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:ig_f <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> i ❑VAPOR ElMUD ROTARY DEPTH OF GROUT SEAL 3TCr• L!L TREMIE TYPE TO BE USED El AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX BORING DEPTH 2O feet Fc]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> well Construction per Workplan and well cons ND R SIN RDPOSED Qf YES,IW spetlriraliw,sln m mem s Ion) <br /> COMMENTS: P P 4,,,8€ibRgr�r�1 <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 prepay this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an 1 Ili, Iifor 'a s. 1 /y/ <br /> Signed l`'G'� Title/Company ///i7/1a7 E/�/& Dir// r <br /> Pdnt Name rr /•(/ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 14 Z 57 La re k-R,o a L4 I ra C V I If A <br /> WORK PLAN DATED:_ M A r'P Yf 10 . 2 0 1 0 <br /> APPLICATION ACCEPTED BY- Vi,C+b rC mtt P.dY'F'nP.r. DATE ISSUED AREA 1115-9 <br /> GROUT INSPECTION BY Y.ci-arta lnG�l4YtA! &/ ,O, FINAL INSPECTION BY r[A tn6 e4,hne -. DATE 3-11-11 <br /> DESTRUCTION INSPECTION BY DATE (y' <br /> COMMENTS/CONDITIONS: �Ytsq-el1(/1'�ien bF MW 28 0Tr-5-,-I-e, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK* RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 3501 Izzx I ,ams: -# >., 1778 '0* IS-10-11 SR# ODG2103 <br /> C-5 WCC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDOC 3GL,00 <br /> EH 29-01 10/28/09 WELL PERMIT APP <br />