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1 <br /> "q�(.y. • SAN JOAQUIN COUNTY • <br /> so.�t.co <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 6 I 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> v4! YP Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br /> �/FONN <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 /> AJJoaquiln,,County Development <br /> Title,Chapter 9-1115.3, <br /> 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> / 31)e <br /> Location T75 I 4tdte 4„ross Street Willow Way&Sequoia Blvd City Tracy Zip 95376 APN N/A(City Sidewalks) <br /> Property City of Tracy 333 Civic Center Plaza Trac 95376 209 831-6000 <br /> Owner //11�� Address City Y Zip Phone ( ) <br /> C-57Contractor IF, /1Z�O�e N�1/•x15 Address 1231 Alixt 9-, St-,kA A city woad I'"J Lie 6)DG K9r7 Phone (�°9 681 -3)01 <br /> T <br /> Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City Oakland Lic WA Phone (510)466-7148 <br /> Billable Party SAIC Address i OO Broadway,Suite 675 City Oakland Zip 94607 Phone (510)466-7148 <br /> GIS Coordinates:X -121.4 y 37.73 .� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> O ❑SOIL BORING IDs <br /> (J WELL IDs MW-9,MW-10,MW-12,MW-14 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC (] OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE _ <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION pa All So.,,.,Oeonel❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface <br /> _[x]OTHER:Well Box Replacement _ (]OTHER: APPROX.BORING DEPTH W BOLTED TRAFFIC BOX OR ❑STOVEPIPE `_k <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS:Well box replacement(4 wells)located on city sidewalks. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applica{q�le�Calif rnia laws. <br /> Signed _ /!�-1��— Title/Company Project Geologist/SAIC <br /> Print Name Sean Gehlke Date <br /> DEPARTMENT USE ONLY <br /> N <br /> SITE MAP IN UNIT IV FILE-SITE ADDRE 506 • 1-1L3 ll . aLr-c-t <br /> i <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 646 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> / REQUEST PR# <br /> 2,q- t) $ 125x s�r 0�83atJ 9 SR#0103 <br /> � o w <br /> PR# <br /> (2900 �J7f7O <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC DiC <br /> EHD 29-01 07/28/10 A en��'/.PERMIT <br />