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s <br /> U San Joaquin CouAty, <br /> nD E n I i MV��✓ # <br /> r Environmental Health Department AU I <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 <br /> Ii A <br /> � NION <br /> (209)468-3449 Frac: (209)468-3433 Web:www% ./ gov.orglehd NVII3O I �I-TH t <br /> ` O well Permit Application PERW <br /> NON-REFUNDABLE PERMfr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor 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 /> Assesson: <br /> WELLLocaWn 3780 'West Linne Road Cross StreetHWY 5 CityTrac Zip95376 Parcel# .255=102-003 <br /> PROPER-g, <br /> Owner onald Sinclair Address3780 West Linne, RoadCfiyTracy ZIp95376 � (209) 833=7517 <br /> C-87Contractor Soil robe _ ____Add1255 N Cherry St. 515 <br /> resCuiare ap93�y 274 j870745Phpna# {559)584-7200 <br /> ir. Geola ical Technics <br /> CoMaltarEtlSub CnV 9 Add1101 7th .StreetCtly Modesto Lid Phone# {209)522-4219 <br /> 013 Coordinates:X Y Township .RanAe Section <br /> f# <br /> NQS%TO BE PERFORMED: <br /> 0 NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') XDESTRUCTION (choose type below) <br /> p SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 13 WELL# 0 PRESSURE GROUT <br /> 1] GROUT SPECIFICATIONS j <br /> COMMENTS:Cestruction of MW-1R, MW-4, MW-2, MW-3, MW-5, and MW-101 See attached Work Plan dated 07/09/07 <br /> TYPE OF MR�L INSTALLATION TYPE CONTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTifFR: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF'GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AUGERS' flHOSE <br /> p AIR SPARGE/OZONE' 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> EI OTHER:. n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOve PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist specifications In comment sedan) <br /> COMMENTS: See Attached WP dated 07/09/07 <br /> NOTE-` OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR-ENCROACHMENT PERMITS. <br /> ` 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 1 <br /> I he rdfy at I have prepared this application.and that the work will be done In accordance with San Joaquin <br /> COU O an ,Rules and Regul Ions,and all applicable California State Laws. <br /> Signed Tma�company. Soilprobe . <br /> Print Name Da -7 bonn <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: b <br /> WORK PLAN DATED: qC7 <br /> Application Accepted By pate Issued $ 0 Am <br /> Grout inspection By Data Final Inspection By Dam 2 <br /> Destruction Inspection By e..1 Data tr7,y9 10 <br /> COtMt# UTS 1 CONDITIONS; <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE$ FEE INFO AMOUNT REMITTED CHECK t RECD BY DATE PERiMIT I SERVICE REQUEST 8 INVOICE <br /> 3To 2 i;v:oo <br /> c ,rva o f`j�sG l B S�o� SR# is <br /> C-57 WC -WAIVER_ C-57 letter of Authorization to sign Pe <br /> rrnit_Encroachment do;._ <br /> EHD 29-02-001 <br /> 6/22/0 i <br /> FILE COPY <br /> ]+ <br />