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(-CjGF1'y7 <br /> SAN JOAQUIN COUNTY <br /> ^"- G ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N; < <br /> ' g :• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> • c�..•-- -..•;P <br /> Telephone: /209 468-3454 Fax: 209 468-3433 Web:www.si9ov.orcl/ehd UNIT IV <br /> 4C%FORa I \ ) ) <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 23513Q32 <br /> yCitof Trac 325 Civic Center Plaz Trac 95376 <br /> owner Property <br /> OwnerY Address aCity Y zip Phone 209-831-6452 <br /> C-57Contractor Penecore Address1238 Alice Ave.Suit ACity Woodland Li, 906899 Phone530-661-3600 <br /> Consultant/SubCntr AMEC Address 101 Webster St. 12 Floorcity0akland Lic 601450 Phone510-663-4133 <br /> Billable PartyChevron Env Mgt COAddress6101 Bollenger Canyon RdCitySan Ramon Zip 94583 Phone 92S-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 /> 0 SOIL BORING IDs East-5 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8r#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ..(� <br /> r <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 /> 1 IN SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [A No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSparge.Ozonel0HAND 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 X <br /> CONDUCTOR CASING 6 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:[I AUGERS El HOSE [I PIPE [I 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 411 aD(oo�lliyic��a--b�lee California Laws. <br /> Signed Title/Company Staff Scientist/AMEC <br /> Print Name Heidi Dietrich-Foronda Date June 51 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_ ZJ ' Ca "'ff ST2C-e-t 1p—r�t <br /> WORK PLAN DATED J Ut K) /Z <br /> APPLICATION ACCEPTED BY O a}p:a K'r DATE I a EA /G <br /> GROUT INSPECTION BY Z ct FINAL INSPECTION BY TE 17/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: i ✓� M i` <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> Cs� REQUEST PR# <br /> 210'�— $125x % SR# S2 50T <br /> 290 3 <br /> 37s- 3500 <br /> PR# <br /> 2900 <br /> C-57— WCy WAIVER 4/4 C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC__t/ <br />