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_- COPY <br /> - <br /> ���;a�.l San Joaquin County <br /> z: G Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 <br /> 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 compliance.:wlth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors 2�t��� <br /> WELL Location �6 W, '6th. St. cross Street Central city Tracy Zip95376 Parcel#-i <br /> 9451 <br /> ' PROPERTY <br /> Owner Union Pacific RR Address Atkinson St. city an Z'p 95747Pno705 <br /> c-57ContraetorVironex Address 2110 Adams city_LeandrePip 94573X#927 Phone#510-568-7676 <br /> Consultant/Sub Cntr Kennedy/Jenks Address 622 Folsom--at—. City S.F. Lic# Phone# 415-7t13-2150 <br /> GIS Coordinates:X <br /> Y Township 2S Range 5E Section 28 <br /> WORK TO BE PERFORMED: THER`) Q DESTRUCTION (choose type below) <br /> Q NEW WELL/BORING (Its(,GEOPROBE,HYDROPUNCH,M Q OVER-BORE. DIAMETER <br /> OIL BORING#_ n .5 s� d JS-.S�IzI Q PRESSURE GROUT <br /> Q WELL GROUT SPECIFICATIONS �p <br /> p•Other /�cj '06, <br /> COMMENTS:— -�� �y /S.Bj 03IU4 ' ZSIS�" "i,--� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_2--LnQ MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes )Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> • KSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Neat CPm nt <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH 2-15 ft. —Q BOLTED TRAFFIC BOX or Q 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 /> ' 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County0 finances, Rules and Regulations,and all applicable California State Laws. aI <br /> � 7f 414,At �_Title/Company (7Q4�6�liSLt <br /> ' Signed x p <br /> Print Name <br /> �1 �`� L . . Date t I AI?10S^ <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: OS y� <br /> Date Issued <br /> '1/ O Area <br /> Application Accepted By U��� <br /> ' Grout Inspection By ate 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 I SERVICE REQUEST# INVOICE <br /> << 36 SR# Q 5p�� <br /> C-57_ WC—WAIVER_ -57 Letter of Authorization to sign permit_Encroachment doc N <br /> EHD 29-02-001 <br /> ' 6/22/04 <br />