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zP°"'� SAN JOAQUIN COUNTY <br /> ......... <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNt'tiVa <br /> �cq...._„-,_•�P <br /> Telephone: 209} 468-3147 Fax: (209)468-3433 Web:www.s" ov.or � <br /> ( / N ' <br /> WELL & BORING PERMIT APPLICATION <br /> gy �� 1013 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct arxLor install the work described. This application is mkA 1p dom�r6an-c with San <br /> Joaquin County D v� eiopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmenta'�i�fli/� <br /> Site Location 99 Fe'a'st 66th Street Cross Street E Street City/State Tracy,CA Zip 95376 APN TC-ity-9treet F� <br /> Property <br /> Owner City Of Tracy Address 333 Civic Center P'lara City/State Tracy,CA Zip95376 Phone(209)831-6400 <br /> ecnicon Engineering Servi <br /> C-57 ContractorThjklabress 4539 N Brawkx kre 4108 City/State Fresno,CA Lic 767888 Phone 559( )276-9311 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Technicon Engineering Address 4539 N.Brawler Ave 811:.8_ City/State Fresno,CA Zip 93722 Phone(559)276-9311 <br /> GIS Coordinates:X N/A Y N/A <br /> ! CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-0-AGE- 0114 <br /> s ❑SOIL BORING IDs <br /> ❑WELL IDs = <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE f! ti p, 411 SPECIFICATIONS <br /> _O MONITORING ❑HOLLOW STEM ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ' _❑SOIL VAPOR PROBE ❑MUD ROTARY .:Al- TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) 2❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —❑INJECTION(i.e-Kir Soarae.Ozone)❑HAND AUGER ONS <br /> ❑OTHER: ❑OTHER: PTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS RE tit( A,.-, w3 AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 3—#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 2 6.5 FT <br /> WELL IDs:MW-1.MW-2 and MW-3 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS _ ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:EI AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS _ <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER rf***T ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that Cw ocil wN'.a done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California laws. <br /> Signed - . Wt rnpany President/CEO-Technicon Engineering Services, Inc. <br /> Print Na vl Darren G.Williams _ Date_G�/a0i� <br /> r- DEPARTIlftht USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTE BY Y/ �c2���r/1�11�2 � _ DATE ISSUED �3 AREA <br /> GROUT INSPECTION BY \ t iNAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENTSICONDITIONS:G9�- ���/ /�7�✓� �� <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQ [EST PR# <br /> $125x 9/7✓-3-. 7Ofi7� hy�" SIR it rO731 <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 ���. ��, WELL PERMIT APP <br />