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San Joaquin County <br /> /< Environmental Health Department <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 M11'IGA'jION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> 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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location Central Avenue Cross Street Sixth Street City Tracy zip 95376 Parcel#_235_150-09 <br /> PROPERTY <br /> owner Union Pacific Railroad CO. Address 1400 Douglas Street City Omaha. NE zip 68179 Phone#402-544-8600 <br /> C-57 Contractor Address Cit; Zip '-ic# Phone# <br /> Gregg n Situ 50 Howe Road Martinez 4J�553 657 925-313-5800 <br /> Consultant/Sub Cntr Geocon Consultants,Inc. Address3160 Gold Valley Drive,#800 City -nch-cord-v- Lic# Phone# 916-852-9118 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [x]NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> [X]SOIL BORING# 8 GeODrobe.6 CPT []OVER-BORE. DIAMETER <br /> [J WELL# 0 PRESSURE GROUT <br /> []`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:______ <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL [J PVC []OTHER: <br /> []VAPOR [J MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> (1 OTHER: [J OTHER APPROX.BORING DEPTH [J BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 /> hereby certify that I have prepare - his application and that the work will be done in accordance with San Joaquin <br /> Cou ty'-Or 'nances, Rul and �g ations, and all applicable California State Laws. <br /> Signed Title/Company Geocon Consultants, Inc. <br /> Print Na e James F.Bra e Date 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: ll <br /> WORK PLAN DATED: To <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date ` ' C Final Inspection By Date <br /> Destruction Inspection B Date <br /> COMMENTS/CONDITIONS: 2_d <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST it INVOICE <br /> az��� �� � ��� �� � a sR# g107 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />