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I <br /> `� <br /> ir , ^ t � <br /> op411'� c <br /> SAN JOAQUIN COUNTY ' ' � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> hi_ SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 <br /> • P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si-ov.org/ehd UNIT IV <br /> FOR�� <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 /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2 3 S /5u ZI( <br /> Site Location 11 W 6th St Cross Street N Central Ave City Tracy Zip 95376 APN <br /> Property UPRR 1400 Douglas St. stop 1690 Omaha Ne 6817 <br /> Owner Address City Zip Phone 4 04-54 4-85 64 <br /> Penecore 1238 Alice Ave.suit A Woodland 906899 Phone 530-661-3600 <br /> C-57 Contractor Address City Lic <br /> Cons AMSC Address101 Webster St. 12 FloorCityOakland Lic 601450 Phone510-663-4133 <br /> Billable PartyChevron Env Mgt CcAddress6101 Bollenger Canyon RdCitySan Ramon Zip 94583 Phone 925-790-6437 <br /> GIS Coordinates:X Y See attached figure <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPR11 BE1H�DROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> l'❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [R No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(ieAir Soarae.Ozone) HAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout -4 <br /> _❑OTHER: OTHERdirect push APPROX.BORING DEPTH 2 5 r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING)J�No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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:F1AUGERS ❑HOSE ElPIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 II aoDlicable California Laws. <br /> Signed "mews Title/CompanyStaff Scientist/AMSC <br /> Print Name Heidi Dietrich—Foronda Date June 5, 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS L) nrly <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE '1 Z 16�I <br /> GROUT INSPECTION BY FINAL INSPECTION 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 /> G p REQUEST PR# <br /> $125x 1 126 ��cU� 1 � r/,' C� {Z SR# 5�7� <br /> 55 3 00 <br /> PR# <br /> 2900) <br /> C-57 WC WAIVER AIL- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /' <br />