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_ a <br /> �oAgU�Nr.ca s • FILE COPY <br /> - AN .10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> l�pg LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si-gov.org/ehd UNIT IV <br /> �rFOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 the San Joaquin County Environmental Health Department. <br /> Site Location 4th St Right of way Cross Street N Central Ave Trac Ca 95376 NA kOtj <br /> Property City/State y Zip APN <br /> Owner City of Tracy Address 325 Civic Center PlazaTracy, Ca 95376 <br /> City/State Zip 209-831-6452Phone <br /> C-57 Contractor Address City/State Lic Phone <br /> Consultant/Sub Cntr AMEC E&I Address 2101 Webster St, 12 Floor Cit /StateOakland, C 601450 <br /> y Ca <br /> is Phone 510-663-4100 <br /> Billable Party Chevron EMC Address 6101 Bollinger Canyon Rd City/Staten Ramon, '�tjp 24583 Phone 925-790-6431 <br /> GIS Coordinates:X Y See attached figure. Well location is in front of 24 4th St. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No E]Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: _DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 1 #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: RSY-1 ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS hydrated bentonite grout ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS Wells were constructed w/ bentonite grout. AMEC will pull out tubing and hydrate bentonite to destroy wells. <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,,�a/nd-all applicable California laws. <br /> Signed Ff� "�suY Title/Company AMEC E&I <br /> Print Name Heidi Dietrich-Foronda Date3/7/14 <br /> c DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS _�'if2[FtC� <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J. ypy}s<ttwl DATE I EA <br /> GROUT INSPECTION BY FINALINSPECTION BY Guitu W1 DTE 3-Z7'1y <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS- <br /> ACCOUNTING ONLY: FREMITTED <br /> FAC# <br /> PE CODES FEE INFCHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2�OZ $125 x 3 3 C'v - 4 SR#RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC _WAIVERPV 14- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ N* ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />