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I - SAN JOAQUIN COUNTY .+ V RIGINAL 'pqutly .g a ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV CtR;;-, --._•.;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd L�Fi7R WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin Count eloDm nt�T e�ChaWr 9 1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 7500 West 11th St. Cross Street Chrisman Road City Tracy Zip 95304 APN 25014014 Propertyy 1{{imQjo Qleo [LTKr9 95304 Owner CarINavarlaLj�Z Address 475 West Blewett Road City Tracy Zip Phone (209)836-0005 C-57 Contractor Gregg Drilling and Testing,Inc Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 Consultant/Sut Cntr tDsi skins,PtiO PE,-GE Address 1120 Ho3lywood Ave.No.3 City OaRland F�GE 28602 i 510)33&4118 rlwr F gl—e end CoponsWctb Inc "`�� f Billable Party '� /Address aa�a south Koster Roec1 .-.City Tracy �Ztpl�3od�° ""� � h n ilF9i s3z-2saD rtSee alSe`che`d aee enacned GIS Coordinates:X •I""""""""`"RY I CONSTRUCTION WORK TO BE PERFORMED: MAY3 269 ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDs n'tL ❑OTHER IDs__....._... PlC !J SERYIGES TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS —❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE �❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION i.e.Air a e Ozone ❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY -2-#OF WELL(S)TO SE DESTROYED OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF�� FT WELL IDS:MW-17 and MW-1a ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Type II Portland Cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USEDE]AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS SEE ATTACHMENTS FOR LOCATION MAP,SITE PLAN,GI$LOCATIONS AND WELL DEPTHS. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 ha prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all ap cable C lifornia ws. Signed Title/Company Geotechnical Engineer,Dietz Engineering and Construction,Inc. Print Name Dai 16atkins Date 4> v3 2cs DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 76-00 GJ . r"a 5'f~ y WORK PLAN DATED tK—wt 'Z APPLICATION ACCEPTED BY J. �p r�Ke u�'t _ DATE IrSIMMREA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# 350 2 $125x K 2. Q5 S-3-13 SR# 17 3.5-03 3 RO# 3500 PR# 2900) C-57 „moi WC v WAIVER N C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC �!4