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SAN JOAQUIN COUNTY �ECEI►ED SEP 0 8 2011 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ' p Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.s' ov.org/ehd <br /> <rFOR� WELL & BORING PERMIT APPLICATIONRECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 14 '­1 <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 complian h San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental HejNW0NWNTAL HEFt.M <br /> Site Location 425 W. Larch Rd, Cross Street Tracy Blvd, City Tracy Zip 9530WERMIT�PIN 1220008 <br /> Property <br /> Owner Frontier Transportation, Inc. Address 3577 West Philadelphia City Chino Hills, CA Zip 91710 Phone (714)408-0418 <br /> C-57 Contractor Gregg Drilling&Testing Inc.Address 950 Howe Road City Martinez Lic 485165 Phone(925)313-5800 <br /> ConsultantlSub CntrAmi Adini&Assoc. Address 4130 Cahuenga Blvd., Ste.113 CityLos Angeles, CA Lic 91602 Phone(818)824-8102 <br /> Billable Party Ami Adim&Assoc. Inc. Address 4130 Cahuenga Blvd Ste 113City Los Angeles, CA Zip 91602 Phone (818)824-8102 <br /> GIS Coordinates:X 6292214.86' Y 2102580.76' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs 11 DPF wells (Dpi) <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: T <br /> _KI EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL ®PVC [ OTHER <br /> _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 3 feet TREMIE TYPE TO BE USED: ❑AUGERS t]HOSE ❑PIPE <br /> _Q SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(i a Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 20 feet P9 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: well Construction per Workplan and well Construction Diagram <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> W—ELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ 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 prepared application and that the work will be done in accordance with San Joaquin County Ordinances. Rules and <br /> Regulations 1 cable C is laws. y/ <br /> Signed ,/ /Yn t� SIeNNEkFJ Title/Compan n A5 <br /> Print Name /U /'Z(/.L'r Date qY F, fT( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 4 Z E W t LarJL R S� <br /> WORK PLAN DATED I -2011 <br /> APPLICATION ACCEPTED BY �q DATE ISSUED ,�-19 - // AREA 1459 <br /> GROUT INSPECTION BYyir6r-e the /o-10-F( FINAL INSPECTION BY)(i4,1,* DATE/0-/Z-/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: lls DPG I - p <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE IN A T REMITTED CHECK# RECV'D BY DATE SERVICE RD# INVOICE <br /> REQUEST PR# <br /> 3501 $121, II �I 3 7S700 1 LOanj 1 n'Cl SR# 004, 3503 <br /> bRO# <br /> 35403 r]S 00 3 -75-, 0 0 3500 S2 <br /> 7 5 0. 00 PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />