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SAN JOA4UIN COUNTY FILE COPY a' '•a ENVIRONMENTAL HEALTH DEPARTMENT LOP ED 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION k::::•• Telephone:(209)468-3454 Fax:(209)488-3433 Web:wwwsigov.orp/ehd UNIT IV FE 0 2 2011 WELL & BORING PERMIT APPLICATION 6;g 2b FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION (Z) ENVIRONMENTAL CHFESALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I APPII RffAIA tlreoy mjd2 b%an 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. �'30 ,�� Site LOOatiOn $ox east grant rens aa. Cross Street North MacArthur City Tracy Zip 95376 APVq/V Property Owner PG&E Address PO Box 770000 City Ban Francisco Zip 94177 Phare (925)383-9517 C-67 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez LIC 485165 Phone (925)313-5800 ng Aeenng n¢ eC on Consultant/Sub Cntr aaaonr«a cmaa Address -585 eeeAem siva., suite 200 City Martinez LIC 743750 Phone (925)969-0750 Billable Party aPeo„-�e„ c:anc Address 4585 P-c -a1W., suite zoo City Martinez Zip 94553 Phone (925)969-0750 GISCoordinates:X 37,7gg _Y=_2I-�� CONSTRUCTION WORK TO BE PERFORMED: ®NEIN WELVBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs"11-4, Aon-5, Aon-1., rw12-2, A012-2,=12-4, m13-1, A013a, A013.3, nolo-1, coxa-z, noxa-2. Ao1s-i Ac1s- 2, AOIS-3 A0I64 ❑WELL IDB -2, A011-1, Aou-z. Amt-s ❑OTHER IDs { TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS nV.\ 61 _❑MONITORING ®HOLLOW STEM DIA OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA; _Q EXTRACTION:Vapod Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CARING: Q STEEL Q PVC Q OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE Q PIPE i ®SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q Yes Ej No(MAXIMUM FREE FALL DEPTH IS 30 FT) _QINJECTION BsAtSoameOmael®HAND AUGER 20 GROUT SPECIFICATIONS Portland cement with St bentonite _Q OTHER: ®OTHER: r gnrohr APPROX.BORING DEPTH 3 to 25 feet Q BOLTED TRAFFIC BOX OR Q STOVE PIPE 1 CONDUCTOR CASING Q No Q Yes:Casing Ole:_Casing Depth:_„ acting Ola'— COMMENTS: wo.eu will ne Lets eoen ana/or ovate m a I n 1 u 1 a a 1ti. a n a Lu a 1 NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APP YI OF VJELL(S)TOBE DESTROYED i ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr 7 WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT.SPECIFICATIONS ❑EXPLOSIVES FROM TO tT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE \� COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 hereby certify that i have pr ared thi pplication and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,a r e Calif aws. / Signed Title/Company / O (� r Print Name O,1 ` DEPARTMENT USE ONLY 29. SITE MAP IN UNIT IV FILE-SITE ADDRESS ✓O 2 Fi• - e WORK PLAN DATED Z'6 - ZO(/ APPLICATION ACCEPTED BY �(j' AREA U6 I GROUT INSPECTION BYlGfiFiNAL INSPECTION BY DATE 5-14—If DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERQVIRO## INVOICE 2405 $122 ! I47,2L.' L S '• RESR#UESTCE PR�fZ34�8 I 29 o OS 0�5 C-57 WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC - EHD 29-01 07/2M100 WELL PER APP