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i SAN JOAQUIN COUNTY :.- ..._._..,c LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION Y. 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • Telephone:(209) 468-3454 Fax.(209) 468-3433 Web:www.siaov.orcglehd FE 1 WELL & BORING PERMIT APPLICATION ENVIRONMENTAL HE5gfflWELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION IPERMITISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 20500 Holly Dr Cross Street Arbor Avenue city Trac Zip25304 APN 21 21601 9 Propsrty Owner_Spreckels Sugar Address P.O. Bax 60 City Traci Zip 95378 Pho4e209 ) 834-7679 C-57 Contractor V&W Dri1ljn_g Address &it�St,()C' ctnt757Lic72QgfL4 Pho4209) 469-7700 Consultan ubCntrr_-ni3nrl 7,ero\ddress 1714 Main St - Cit yFcralr1:n LiTG$4j Phor(e?09) 838-9888 Billable Party Address City Zip Phone • GIS Coordinates:X 3 7 46 ' 17 . 15"N _ j 2 1r 7 5 r 1 . 55_" W - CONSTRUCTION WORK TO BE PERFORMED: dEW WELU13ORING(CPT,GEOPR03E,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING I^- [SI WELL IDs_t'YN - ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �[ MONITORING ERHOLLOW STEM DIA.OF BOREHOLE 49.11 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _(]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2" d i a m TYPE OF CASING: ❑STEEL IDPVC ❑ OTHER _❑SOIL VAPOR PR09E Cl MUD ROTARY DEPTH'OF GROUT SEAL 9 f P_P t:TREM IE TYPE TO BE USED: ❑AUGERS ❑HOSE 7 PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes EA No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i,e.RirSoaroe.Ozone/❑HAND AUGER GROUT SPEC?FICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 f P_p t. :p BOLTED TRAFFIC BOX OR ❑STOVF PIPE CONDUCTOR CASING}No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELLS)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-a[[app' able California laws. Signed � _-_ w ^_ � _TitlelCompany Ge Olocrlst/Gr_ound Zero Analysis , Inc. Print Name Er i 0 L_ P r i c Date zI C'Z- I I I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Q r LOP WORK PLAN DATED l( I 1 APPLICATION ACCEPTED BY DATE ISSUED ( AREA GROUT INSPECTION BY 4rFINAL INSPECTION BY DATE Zf f i DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: 114_ 4 C f W (4 l ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q REQUEST 4 PR# Sa� $122. I Z.� �`'Sb L^�fC 1 it SR# (0 a ! b„ 5v313(dam - (3500 PR# ,VIA 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 9-01 07/28/10 WELL PERMIT APP i