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Pq�iM• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N' � :`• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> • q..-•- ..;P Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.ora/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 Palk Street Cross Street Wagtail Drive City Tracy zip 95376 APN 23-52R017 <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-57Contractor Penecore Address1238 Alice Ave.Suit ACity Woodland Lic 906899 Phone 530-661-3600 <br /> Consultant/SubCntr AMEC Address 101 Webster St. 12 F1oorCityOakland Lic 601450 Phone510-663-4133 <br /> BillablePartyCheyron 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 SOIL BORING IDS S EOPPnBE.�-IxDROPUNCH,HAND-AUGER,OTHER) <br /> OU <br /> El WELL IDs 1 L <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 /> _XI SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes U No(MAXIMUM FREE FALL DEPTH IS 30 FT) r <br /> _❑INJECTION(I.e.AirSgarae.Ozone) HANDAUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout <br /> _❑OTHER: OTHERdirect push APPROX.BORING DEPTH 2 5 ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE rt <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) C <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,andII aoolicable California Laws. <br /> Signed /11L o 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 w G rN 5 7'k-°" 7127&y <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY 0 DATE IV !d . / EA /6 <br /> GROUT INSPECTION BY FINAL INSPECTION BYDATE G L <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 /> GREQUEST I PR# <br /> v� $125 x f 2 2 0<�q I Ct4 G U 12 SR# 07 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 // WC WAIVER it C57 LETTER OF AUTHORIZATION TO SIGN PERMIT J,/ ENCROACHMENT DOC <br />