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f � � <br /> ' oink San Joaquin County <br /> Environmental Health Department SITE <br /> y 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> i <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 /> the work <br /> escribed. This <br /> ication is <br /> JApplicaon is hreby made to San oaqu ntlCountyeDeve Development Title,loaquin County Chapter -11 5.3ra permit to construct and the Standards of San/or Joaquinl County Environmental Health IDepartmentade in --n��.. fh c°^ <br /> Assesso"so-'�S�50�� <br /> WELL Locatiorj//� to Y� Tracy Cross Street Central city Tract/ zip 95376 Parcel# /41-111- W <br /> PROPERTY Atkinson St. RosevilleZip 95747 Phone# <br /> ' owner Union Pacific Railroiress city <br /> an 705 <br /> C-57 Contractor V I r0 n e X <br /> Address 2110 Adams Ave- City Leandrcrip 9457'Lic#927 Phone#510-568-7676 <br /> Consultant/Sub Cnk Kennedy/jertks Address 622 Folsom—St. city S.F. Lic# Phone# 415-243-2150 <br /> GIS Coordinates:X <br /> y ,Township 2S Range 5E Section 28 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (RDD,GEOPROBE HYDROPUNCH,I p?ipl> ttGH13KOTHER*) p DESTRUCTION (choose type below) <br /> ,� OVER-BORE. DIAMETER <br /> SOIL BORING# a <br /> ---r- /�(''r5� �6U�/ 0 PRESSURE GROUT <br /> 0 WELL# �'(�(/ T -- GROUT SPECIFICATIONS - <br /> p*Other TiIl/>b D 2 /✓4 <br /> ' COMMENTS: OZ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2-in a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ' EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: G STEEL U PVC Q OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> AIR SPARGE/OZONE)WUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �. )WOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> U OTHER: a OTHER APPROX.BORING DEPTH 15 ft. Q BOLTED TRAFFIC BOX or a 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Repgulations,and all <br /> applicable California State Laws. / <br /> /j'l c.�� � f-cc�C na►�s�L"—Title/Company C)£0/ **SLS X7/4 d <br /> ' Signed x <br /> Print Name 1'r��"`"^ MG�C/d P G Date �� �� <br /> DEPARTMENT USE ONLY �r <br /> SITE MAP IN UNIT IV FILE, DRESS: �/ w, 6 m J C <br /> WORK PLAN DATED: ?i1 0C,7-0f <br /> ` Area <br /> Application Accepted By Date Issued Date <br /> Grout inspection By Date Final Inspection By. <br /> Destruction Inspection By Date <br /> ' COMMENTS/CONDITIONS: <br /> ACCOUNTVW -WLAEOP <br /> FAC# <br /> PE CODEST REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# 7INVOICE <br /> ' � <br /> • C-57 IV _ C-57 Letter of Authorization to sign permit✓Encroachment doc N <br /> ' EHD 29-02-001 <br /> 6/22/04 <br />