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FILE COPY <br /> oP°`'t"•c 4kan Joaquin County- <br /> Environmental <br /> ounty <br /> Environmental Health Department SITE <br /> LO { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <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 rmmnlin­-4th ems„ <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> y� Assesso-- <br /> WELL Locatior �� �l/• (0/ Tracy Cross street Central city Tracy zip 95376 Parcel# 7-55/5014 <br /> PROPERTY - Atkinson St. Roseville 95747 /44" 17fOwner Union Pacific RailrO&&ress City Zip Phone# <br /> C-57 ContractorVironex Address 2110 Adams Ave. city an Leandr�ip 9457Tic#7927 Pnone#510-568-7676 <br /> Consultant/Sub Cntr Kennedy/Jenks Address 622 Folsom St. city S.F. Lic# Pnone# 415-243-2150 <br /> GIS Coordinates:X Y Township 2S Range 5E Section 28 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (91W,GEOPROBE.HYDROPUNCH,HAi50 I MR0K OTHER*) 0 DESTRUCTION (choose type below) <br /> X SOIL BORING#� - �r OVER-BORE. DIAMETER <br /> 0 WELL# / 1/I��fl��1y Q�,�/ PRESSURE GROUT <br /> 0*Other 1 GROUT SPECIFICATIONS <br /> COMMENTS: OZ Qu" Z35i50 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2—in 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)WUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> )WOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 15 ft. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: <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 in accordance with San Joaquin <br /> County Ordinances, Rules a�n/d Regulations, and all <br /> applicable California State Laws. <br /> Signed x /` c/ Z��f-ca�C ��n`✓y/Title/Company 6,e 0'/0 "5e Lasl�e o� <br /> Print Name (til;G4aX • / �GLt"Z P G, Date I L'€ 0,5' <br /> DEPARTMENT USE ONLY T� <br /> SITE MAP IN UNIT IV FILE, DRESS: <br /> WORK PLAN DATED: AOU,, 74 O c,TOs <br /> Application Accepted By Date Issued ` Z' Area (1lO/v <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> A � S R# <br /> C-57 W --WAIVER- C-57 Letter of Authorization to sign permit ✓Encroachment doc N <br /> EHD 29-02-001 <br /> 6/22/04 <br />