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i� SAN JOAQUIN COUNTY b ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV FE� -- 1 Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigoy.org/ehd � R WELL & BORING PERMIT APPLICATION ENVIRONMENTAL HEXCMWELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 20.5. 00 Holly Dr Cross street .Arbor Avenue City Tracy -zip 95304 APN 2121601 0 Propert Ownerpreckels Sugar Address P.O. Sox 60 City Tracy -zip 95-378 Phor(e209 ) 834-7679 C-57 Contractor V&W .Dr'i l l inn Addres6806 Durk rreek niCity,,Rt•nr'g�57Lic-L2D_ga_4__Phor6209) 46_9-7700 ! Consultan ub Cntr_G_r n i i n(7 7 a r&dress 1714 Main St _ Cit LicPC 414 Pho42 0 9_) 838-9888 Billable Party - Address City Zip Phone i GIS Coordinates:X 3 7 4 6 ' _17.35"N _ t{ r �CONSTRUCTION WORK TO BE PERFORMED: {LWE—W WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING!^� ®WELL IDs t^r1 ❑OTHER Ips TYPE&#OF WELLISORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS LIR MONITORING t3tH6LLOW STEM DIA.OF BOREHOLE q It ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS 2 i a M TYPE OF CASING: ❑STEEL WVC ❑ OTHER j —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL�_ f e e f REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE h _❑SOIL BORING' ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:El Yes IR No(MAXIMUM FREE FALL DEPTH IS 30 FT) �❑IWLCTION(i.e.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH —2a.-.f ee.t: -1j7 BOLTED TRAFFIC BOX OR ❑STOVEPIPE COMMENTS: CONDUCTOR CASING J�No[:]Yes:Casing Dia: Casing Depth:- Boring Dia: NOTE: OFFSITE WELLS 8" BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all app' able California laws. Signed �,C �- Title/Company Geologist Ground Zero Inc. Print Name E Zvi C. T.- P r 1CDate Z1 O L it t I DEPARTMENT USE ONLY rr F SITE MAP IN UNIT IV FILE-Sl E ADDRESS O r l f/i WORK PLAN DATED ,L r I APPLICATION ACCEPTED BY DATE ISSUED i1 « AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE)7 l,( 4)II i DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: 4_C-C ACCOUNTING ONLY: AID# FAC# ` PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE (, ! �j / REQUEST 6PR# SO 1 $122x t I Z Z `��, (— i 1L '1 SR# (9 Ro# 3sao /t $ PR# /� F 2901} ~' C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28110 WELL PERMIT APP