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h _ <br /> SAN ,JOAQUlN COUNTYORIGINAI <br /> j`'`�` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> '•< <br /> = 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> •.. ;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siclov.org ehd <br /> Ll FURS <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 7500 West 11th St. Cross Street Chrisman Road City Tracy Zip 95304 APN 25015018 <br /> Propert 95304 <br /> Owner &Klm ra Address 475 West Blewett Road City Tracy Zip Phone (209)836-0005 <br /> C-57 Contractor Gregg Drilling and Testing,Ine Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800_ <br /> COnsultant/Sut Cntr DailNatklns,PhCFPE;GE%address 1 20 1-10 lywood ve.No.3 City Oakland_Ljc GE 28602) Phone (510)336-9118 <br /> Billable Party fDI.L Enp11de`n-Ae �Addre55 3323 South Koster Roetl. Cjty:Tfacy rZlp�. tl D e (209)832-2910 <br /> lig+- <br /> r}] <br /> GIS Coonan'I tss X $°B ellecha`d----IY see anecneq <br /> CONSTRUCTION WORK TO BE PERFORMED: MAY 03 2013 <br /> ❑NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDsA!T <br /> ❑OTHER IDs F_ IVI 'illi " ' '–E '– <br /> TYPE&#OF WELUBORING 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> $ #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT <br /> WELL IDS:MW-1,MW-2,MW-3,MW-3A,MW-3B,MW-4,MW-12 and MWA2A ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Type][PoNandCement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USEDM AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS SEE ATTACHMENTS FOR LOCATION MAP,SITE PLAN,GIS LOCATIONS AND WELL DEPTHS. <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all appli ble California LIWS. <br /> Signed I Title/Company Geotechnical Engineer,Dietz Engineering and Construction,Inc. <br /> Print Name Dai Will6kinsDate C <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 00 W, ( S T 4 <br /> WORK PLAN DATED Nd M t tv <br /> APPLICATION ACCEPTED BY .I•y0 DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'0 BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3� 2 <br /> $125x 2 Y 6-3-'3 SR# (- 7 1 7 Z <br /> 3�0 �j 37 RO# <br /> S 3500 <br /> PR# <br /> 2900 <br /> C-57 WC ��WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT rV ENCROACHMENT DOC Jy-4 <br />