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pUl/Y SAN JOAQUIN COUNTY ORIGINA' ENVIRONMENTAL HEALTH DEPARTMENT LOP ; SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.siclov.org/ehd 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 Countyel Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. O Site Location 7500 West 11th St. Cross Street Chrisman Road City Tracy Zip 95304 APN 25014017 Property 3urL9 (hv,9i S rrS 95304 209 836 0005 Owner. aR�► Address 475 West Blewett Road City Tracy Zip Phone C-57 Contractor Gregg Drilling and Testing,Inc Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 'Wit 20oywood Ave,No:3 OaRlan7f}"�—�j�GE 28fi02 (510)336 9118 Consultantl$ultCntr D-31 PG —City GIS .°e1Z EAS a° Address CIhTracyIp k— Billable Party( Coordinates:,,X � �"ted Y Seea6Ja° CONSTRUCTION WORK TO BE PERFORMED: l W I ❑NEW WELLfBORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER) ❑ SOIL,BORING IDs CA ❑WELL 1D5 i`.11 wlr.1'+ Z ❑OTHER IDs QTr t 1 IYIV��+ TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS CI MULTI-LEVEL WELL CASING DIA: ,,,`❑EXTRACTION:Vaporl Water ❑HAMMERlORIVEN 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 sparge.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 & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY -6 _#OF WELL(S)TO BE DESTROYED ✓ VER-BORE DIAMETER OF s — INCHES TO DEPTH OFs--- FT WELL IDS:MWFP-1,MWFP-3,MWFP-4,MW-14,MW-15 and MW-16 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS TYpa II Portland cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED M AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS welts 1O 136ye,e edrilled with an a in.die auger eY t MW-14 where a 12 in.a LW will t�used..SEE ATTACHMENTS FOR LOCATION MAP,SITE PLAN.GIS LOCATIONS AND WELL DEPTHS. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th41hav prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,andable Califor Laws.Signed TitlelCompany Geotechnical Engineer,Dietz Engineering and Construction,Inc. Print Name Dai WDate OJ O 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED vlr! ,1 I Z APPLICATION ACCEPTED BY J K DATE IS Ep GROUT INSPECTION BY FINAL INSPECTION BY TE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3 502 S 125 x ` 7TO #1 � � SR# 7 7(p 03 3 7 5 375 2 - RO# 3500 PR# C-57 Ll WC 2900 WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC i