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SAN JOAQUIN COUNTY FILE Copy <br /> ENVIRONMENTAL HEALTH DEPARTMENT.) SITE <br /> � ; i <br /> 600 East Main Street, Stockton, CA 95202-302 f� <br /> "� J, - <br /> �f lE ' TIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:WWW.s � — ='UNIT IV <br /> WELL PERMIT APPLICATION J A. 4 2 G 20is9 jwj ) x <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE �tppt/t }pl�I:.��i ii��t//-��IEA+� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This filion tS mdcl� ompliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well . Assessor's <br /> Location 400 W Gandy Dancer Drive Cross Street Tracy Blvd City Tracy Zip 95377 Parcel# 248-030-02 <br /> Property <br /> Owner Dow Chemical Company Address PO Box 8361, Bldg 2000, 3200 Kanawha Turnpike City S. Charleston,WV Zip 25303 Phone# 304.747.700 <br /> C-57 Contractor RSI Drilling Address 220 N. East Street City Woodland Hills Zip 95776 Lic# 802334 Phone# 530.668.2424 <br /> Consultant/Sub Cntr URS Corporation Address 221 Main Street,Suite 600 City San Francisco Lic# 560739 Phone# 415.896.5858 <br /> GIS Coordinates:X -121.43224 ,Y 37.70646 Township T3S Range Section sec4 <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ® DESTRUCTION(CHOOS TYPE BELOW) <br /> ❑SOIL BORING# ®OVER-BORE DIAME 10-inch <br /> ❑WELL# ❑PRESSURE G <br /> ❑'OTHER GROUT SP CATIONS Portland Type II (below) <br /> COMMENTS: Destruction of 4 2-in monitoringwells: TW-1—TW-4. Hollow Ste ver-drill each MO <br /> well with 10-inch <br /> augers to the original installation total depths (69 to 75 feet bas) plus an additional foot to depths from 70 to 76 feet bqs Tremie <br /> grout all borings with neat cement grout to the ground surface using Portland Type II cement with 5% bentonite Mixture ratio of(1) <br /> 94-lbs bag of cement to 5-6 gallons water.Soil derived cuttings will be sampled and stockpiled in a secure droll off bin onsite <br /> pending laboratory results for proper profiling and disposal offsite <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING N HOLLOW STEM DIA_OF BOREHOLE 8-inch ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA:2-inch <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:M Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Portland Type II Cement with 5%Bentonite(94-lbs/5-6-A water) <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX 3 traffic boxes OR ®STOVE PIPE 1-stove <br /> COMMENTS:Well Total Depths (feet bqs):TWA (75-ft) TW-2(70-ft) TW-3(70-ft) TW-4(69-ft) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed L:.CaCx(� Title/Company Senior Geologist/ URS Corporation <br /> Print Name Cr4�9 T,ba /(t Date 0/42/` <br /> [� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> WORK PLAN DATED: Q <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# F11 r PUY <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVIC <br /> �G SR# 6 y <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br />