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- � • • >�• a_,F•.. SAN JOAQUIN COUNTY FELE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION ' 600 East Main Street, Stockton, CA 95202.3029 UNIT IV •.. o:.�'P Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.s*CIov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION q NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Applicalion 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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 502 East Grant Line Rd Cross Street North MacArthur City TraCy Zip 95376. APN Property Owner PG&E Address PO Box 770000 City San Francisco Zlp 94177 Phone (925) 383-9517 C-57 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez Lie 485165 —B _ CarTon Phone (925) 313-5800 Consottant/Sub Cntr eeeuvrce.Green Address eses eaoheco alvd., suit. zoo City Martinez Lie 747350 Phone (925) 969-0750 Enginnerang/ae,xdtactan Billable Party ex„.,,,.�.. �.,,.�, Address 4565 eachece Blvd., suite zoo Ci Martinez City Zip__147350 Phone (925) 969-0750 GIS Coordinates:X 37.748 Y—121.416 CONSTRUCTION WORK TO BE PERFORMED: W NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) �IZ ®SOIL BORING IDs A021-1. n02t-9 nOQ-;, AOIR-6 AOIl-7 AOI]-B A013-9 i0i<- 0 -9 Ifi- AO 6 {. 7 ❑WELL IDs ❑OTHER IDs I TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i _❑MONITORING El HOLLOW STEM DIA.OF BOREHOLE s- t_s•❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA EXTRACTION:VaporiWater ❑HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: O STEEL ❑PVC ❑ OTHER K i _Q SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 11 PIPE `t� ..5.1®SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 1 _pINJECTION T,.B.AirSlwr 0,10 HAND AUGER 13 GROUT SPECIFICATIONS Portland cement with 5% bentonite i .o OTHER: ®OTHER: Geoorobe APPROX.BORING DEPTH 3 feet to 15 feet[3 BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING D No[IYes:Casing Dia: Casing Depth:_ Boring Dia:_ COMMENTS:wo irorin.xt{l be left / b 1 h 11 t 11 kffl dtilled I NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS j DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHEcl<aLL rHATAPPLn I _#OF WELL(a)TO BE DESTROYED LlOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT 1 WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM To FT BELOW SURFACE 1 TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PiPE ❑MUSHROOM CAP[IAT L3 FT) FT BELOW SURFACE 4%. i COMMENTS �yI 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have pared this!pcation and that the work will be done In accordance with San Joaquin County Ordinances,Rules and I Regulations,a ppl aree Callfor i s Signed Title/CompanyOng! { f '*'qae Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS , T WORK PLAN DATED W- ( APPLICATION ACCEPTED BY ■ ■ AREA ! j GROUT INSPECTION BY FINAL INSPECTION _ DATE / DESTRUCTION INSPECTION BY DATE _ CONIMENTS/CON DITIONS: ACCOUNTING ONLY: AID# FAC# PECODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE RO0 INVOICE REQUEST PRO 2905 5122. I 122 i at, SRS 9 05 31Ms 366.' OIo9�43 '�6 3 L9 39 # PR 99oo IDS C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMITFnjjr—ENCROACHMENT DOC EHO 29-01 07/28/10 WELLPER TAPP __ ---_ _ FILE COPY