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0`'1N SAN JOAQUIN COUNTY n � � � ) h , A, � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.org/ehd UNIT IV <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. <br /> Site Location First Street Cross Street C Street City Tracy zip 95376 APN 23.5130-32 <br /> PropertOwner City of Trac 325 Civic Center Plaz Trac 95376 <br /> owner Y Y Address aCity Y zip Phone 209-831-6452 <br /> C-57 Contractor Penecore Address1238 Alice Ave.Suit ACity Woodland Lic 906899 Phone530-661-3600 <br /> Consultant/SubCntr AMSC Address 101 Webster St. 12 Flo <br /> orcityOakland Lic 601450 Phone510-663-4133 <br /> Billable PartyChevron Env Mgt CoAddress6101 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,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs Eas t-5 <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 t <br /> I <br /> 10 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 12 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(ie Air Sparge.Ozone) HAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout 1 <br /> _❑OTHER: OTHERciirect push APPROX.BORING DEPTH 2 5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING]No❑Yes:Casing Dia: Casing Depth: Baring Dia: �. <br /> COMMENTS: rk <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 L? <br />