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Pg�ln SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> •,Z <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sictoy.orcl/ehd <br /> �tFOR� <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 /Su Z'-( <br /> Site Location 11 W 6th St Cross Street N Central Ave City Tracy Zip 95376 APN-9R� — <br /> Property UPRR 1400 Douglas St. stop 1690 Omaha Ne 6817 <br /> Owner Address City Zip Phone 404-544-8564 <br /> C-57Contractor 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 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 SOU BORING IDS J OU Pt??.EPDROPUNCH,HAND-AUGER,OTHER) <br /> El WELL IDs 1 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 rr ❑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-a SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IR No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(I.e.AirSparge.Ozone) HAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout <br /> _❑OTHER: ]OTHERdirect push APPROX.BORING DEPTH 2 5 r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING It 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:❑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 ao�oylic..�a-b-�le California Laws. <br /> Signed Title/Company Staff Scientist/AMEC <br /> Print Name Heidi Dietrich—Foronda Date June 5, 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_II 1j r',ry S T/tK L 7_P,&(ti <br /> WORK PLAN DATED ,u NE (�- <br /> APPLICATION ACCEPTED BY �.`�o4K-41 DATE IS ' A 16.q <br /> GROUT INSPECTION BY J� FINAL INSPECTION BY E � 27 <br /> / - <br /> DESTRUCTION INSPECTION BY "��� DATE <br /> COMMENTS/CONDITIONS: 1tw ti <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR* <br /> 0 S $125x 125 ZGV 14 P -1 Z SR# CRS U 7 Z <br /> ✓� 1 vS 7J 300 <br /> PR# <br /> 290o <br /> C-57_ WC WAIVER Al(fir C57 LETTER OF AUTHORIZATION TO SIGN PERMIT li ENCROACHMENT DOCS <br />