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1 � <br /> 4DIn. <br /> • SAN .JOAQUIN COUNTY FILE COPY <br /> °'r ? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> yy K SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> d4�iFoa�:P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaoy.org/ehd <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. 2oq— 220—c?q <br /> la?;? 209-27104 <br /> Site Location 15101 Schulte Ed Cross Street Bassen Road City/Slate Tracy Zip APN <br /> Property Pier 1, Hay 1 San Franc co, CA 9411 415-733-9431 <br /> P K1f proiogis, L.P. Address City/State 'Zsip 1Phone <br /> Owner 530-661-3600 <br /> PeneCore Drilling Address 220 N East Street City/State <br /> Woodland,CA LIc 906899 phone <br /> C-57 Contractor sac:amenm, a 916-863-9360 <br /> Consultant/Sub Cntr Versar, Inc Address 5330 Primrose Dr #147 City/State Llc Phone <br /> Billable Party Versar,Inc. Address See Above CitylState Zip Phone <br /> GIS Coordinates:X N 37 43.337 Y W 121 30.440 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Q]SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER to <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2_ ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER <br /> _❑ Sbgs SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE EJ PIPE <br /> 2 ❑SOIL BORING 6 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION II e ti Soaroe Ozonel 0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: [I OTHER: APPROX. 40'-50'BORING DEPTH [3 BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Ola: Casing Depth:_ Baring Dla_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECKAUL THATAPPLYI <br /> #OF WELL(S)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: <br /> E]PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS C]EXPLOSIVES FRoM TD FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:C]AUGERS 0 HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appJl able C,aptpmla laws. �/ I <br /> / 1f\/1"�-' t - Title/Company yPi✓rC�/ �Nc Qpv/q/rayrJ ai+uJ ar <br /> Signed \_ !t U <br /> ��h7 Nei e� Date 10 ll¢ /2013 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1(.p (O I SLI Kat-rc Qct <br /> WORK PLAN DATED OCrU & 1 2013 EA X?APPLICATION ACCEPTED BY �Y r qKU vo DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY S=ATE T/7-13 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST FIR# <br /> 0290 $12.5x 1 c>7 f8yy;1 Eimer /afB-f3 Ro# 3l <br /> 4dz 378 �"�r� 3500 <br /> PR# <br /> 2900 <br /> C-57� WC WAIVER�— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �/ ENCROACHMENWDO ELL PERM <br /> END 29-01 5/09/12 <br />