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Wap FILE COPY <br /> U ly San Joaquin` County <br /> /z z Environmental Health Department SITE <br /> 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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors 1e <br /> WELL Location 56 W• 6th. St. Cross Street Central city Tracy zip95376 Parcel# <br /> 451 <br /> PROPERTY <br /> Owner Union Pacific RR Address Atkinson St. City Zip 95747Phone# <br /> San 705 <br /> C-57 ContractorVi ronex Address 2110 Adams city Leandre_ip 94577ic# 927 Phone# 510-568-7676 <br /> Consultant/SubCntr Kennedy/Jenks Address 622 Folsom St. city S.F. Lic# Phone# 415-243-7150 <br /> GIS Coordinates:X ,Y Township 2S Range 5E Section 28 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (AM,,GEOPROBE,HYDROPUNCH, j q*WOTHER.) 0 DESTRUCTION (choose type below) <br /> WOIL BORING#_ q551 <br /> 0 OVER-BORE. DIAMETER <br /> []WELL# �!/ U ^3 dJS�.S4�Z1 0 PRESSURE GROUT <br /> Other <br /> * i JJJ GROUT SPECIFICATIONS <br /> [] <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2—i n0 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 Or GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> KSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Gement <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 2-15 ft. 0 BOLTED TRAFFIC BOX or []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 Or inancpes, Rules and Regulations,, and all applicable California State Laws. <br /> Signed x X7,4 ,�'r111 Z '�/A'1'e• Title/Company �P0�6 . t <br /> Print Name I"i '� I • . Date t /L9�0�' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6 &4 6 47 r <br /> WORK PLAN DATED: oS <br /> Application Accepted By Date Issued 2 Area <br /> Grout Inspection By ate Final Inspection By TERto (I/- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> 7 <br /> PPE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ -57 Letter of Authorization to sign permit_Encroachment doc /U <br /> EHD 29-02-001 <br /> 6/22/04 <br />