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r COPY <br /> q�ln. SAN JOAQUIN COUNTY QIAFcR 13 01 � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3IRONMENTAL HEAIAE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:Www i olS� ��1 S UNIT IV <br /> Cikoat' <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 502 B. Grant Line Rd. Cross Street MacArthur Blvd, City Tracy Zip 95376 APN 250-270-08 <br /> Property <br /> Owner Pacific Gas & Electric Address 3401 Craw Canyon Road City San Ramon Zip 94SR3 Phone g 5-41 -6a 8 <br /> C-57 Contractor Penecore Drilling Address 1238 Alice Street City Wnndward LIC gn6a94 Phone Si0-661-1bnn <br /> Consultant/Sub Cntr Parsons Address 100 W. Walnut Street City Pasadena LIC CA Phone 626-440-6067 <br /> Billable Party Parsons Address 100 W. Walnut Street City Pasadena Zip CA Phone 626-440-6067 <br /> GIS Coordinates:X 37.748 Y-121.415 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> (DWELLIDSmw-5R MW-6 MW-7, MW-8, MW-9. MW-10. MW-1] MW- 7 MW-] MW-14 <br /> ❑OTHER IDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -LQ® MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 10 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4" <br /> _I]EXTRACTION.Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch. 80 TYPE OF CASING: O STEEL O PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 3' bgs 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(is Air Soame Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite chins <br /> _I]OTHER'. ❑OTHER: APPROX.BORING DEPTH 27 feet ®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 /> PK�IUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO <br /> ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: N A PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS OM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT > FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have prepared is application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatigaf and all applZ <br /> ' ble C p x(Lgws. <br /> Signed ,✓m 7. Title/Company Principal Geologist <br /> Print Name Brian K. Eytcheson, P.G. 4/I�IZ <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS .S 66It4VT-k 1A/F A.d <br /> WORK PLAN DATED -13-1 Z <br /> APPLICATION ACCEPTED BY _ J •J019-Ka DATE REA' /6 99 <br /> GROUT INSPECTION BY FINAL INSPECTION BY If iATE -2 -!Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> EPECODESFEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQU/ES,T/ PpR#$125X /O 19-9 CD o z-z'3UL �y'�' -13-12 SR# 64 7(:J S <br /> 37S 37 S RsOooi900 5 °oO'5iC3 <br /> -5WC WAIVER /VV__ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOCS_ <br />