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P4"ty SAN JOAQUIN COUNTY a R I G 6 N i'f <br /> -` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> .cq�/Foy�P <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.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 Polk Street Cross Street Wagtail Drive city Tracy zip 95376 APN 2-15 80. 7 <br /> ProperOwner Cit of Trac 325 Civic Center Plaz Trac 95376 <br /> Owner Y Y Address aCity Y zip Phone 2 09-831-6452 <br /> C-57 Contractor Penecore Address1238 Alice Ave.Suit A City Woodland Lic 906899 Phone 530-661-3600 <br /> Consultant/SubCntr AMEC Address 101 Webster St. 12 F1oorCityOakland Lic 601450 -4133 <br /> Consultant/Sub <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 WELUBORING(CPT,GEOP ?rf H DROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs SOU 1l-7 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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 /> SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IR No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> T <br /> _❑INJECTION(Ie.AirSoaroe.Ozone)QHAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout <br /> _❑OTHER: P OTHERdirect push APPROX.BORING DEPTH 2 5 r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING]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) C <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ElPRESSURE 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 II aoolicable California Laws. <br /> Signed =- Title/Company Staff 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 G rly S 716Ct <br /> WORK PLAN DATED u+vG S Z-0/ 2 <br /> APPLICATION ACCEPTED BY DATE I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B <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 /> c� REQUEST PR# <br /> $125X /Z � 2�tU l� ( 4t�� �oT> �2 SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC d <br />