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FIL <br /> P°��l"• SAN .10AQUIN COUNTY ECOPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE UNIT MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.ora/ehd <br /> �iFOR� <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 23523037 <br /> PropeOwner of Trac 325 Civic Center Plaz Trac 95376 <br /> owner Y �' Address aCity Y Zip Phone 209-831-6452 <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 ELL/BORING(CPT,SOIL BORING IDS S u BEP}1 DROPUNCH,HAND-AUGER,OTHER) <br /> C1 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 /> 1SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[IYes IR No(MAXIMUM FREE FALL DEPTH IS 30 FT) T <br /> _❑INJECTION(I.e.PJrSoarae.Ozone)0HAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout j3 <br /> _❑OTHER: R3 OTHERdirect push APPROX.BORING DEPTH 2 5 r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE rt <br /> CONDUCTOR CASING J' 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and qll aoDlicable 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 It W 6 tw S 7k<-1- 7&17d <br /> J y <br /> WORK PLAN DATED u rvG- I S I ZP/ 2 <br /> APPLICATION ACCEPTED BY j DATE ISSUED CD -/2 AREA /G 9� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 I RO# INVOICE <br /> REQUEST PR# <br /> �1US $125X l Cric (ov �2 SR# v?y <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 V WC 7WAIVER W C57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC k-' <br />