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FILE Copy <br /> Pq�"�• SAN JOAQUIN COUNTY <br /> "- ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y KC <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> c�..__. ...�P• <br /> Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.smgov.org/ehd UNIT IV <br /> 9C%FORS P ( ) ( ) <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 23513032 <br /> PropertyCity of Tracy 325 Civic Center Plaz Trac 95376 <br /> Owner Address aCity Y zip Phone 2 0 9-8 31-6 4 5 2 <br /> C-57Contractor Penecore Addressl238 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 /> 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 GEOPROB ,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs)East– <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> " <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 131 <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 <br /> 1 ff 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 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE S <br /> CONDUCTOR CASING b 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:El AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP AT L3 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 qII aoolicabie California Laws. <br /> Signed ' 's� 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 STP_C-C--r l-p–0')�f 0 <br /> WORK PLAN DATED J Lt K./ ?P(Z_ <br /> APPLICATIONACCEPTED BY I •` o P�o'u wl DATE ISSUED AREA <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 RO# INVOICE <br /> REQUEST PR# <br /> 2�0'�_ $125x / 6,0'4 41 Lr rl� SR# SkW4 _OP <br /> 290 3 7 — s 00 <br /> PR# <br /> 2900 <br /> C-57- �'-_ WC v WAIVER /Lam— C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC��/ <br />