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`mow_• oPqu(N C � �-r '� <br /> SAN JOAQUIN COUNTY ...� <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232I E MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sjqov.orQ/ehP­(-_-- IM <br /> �:.r- <br /> t F O R v �vcc� E <br /> WELL & BORING PERMIT APPLICATION +, qY 2$ 2013 <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 and/or install the work described. This application is rrr, V' NTA&nTH <br /> Joaquin County Dvent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departme <br /> Site Location 99 st 6th Street Cross Street E Street City/State Tracy,CA Zip 95376 APN-G4Y-Street <br /> Property <br /> Owner City of Tracy Address 333 Civic Center Plaza City/State Tracy,CA Zip95376 Phone(209)831-6400 <br /> C-57 ContractorTechn icon Engineering ServiAfress 4539 N.Brawley Ave.#108 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.Brawley Ave.#108 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-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarag.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑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 /> 3 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 26.5 FT <br /> WELL IDs: MW-1MW-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 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 /> Regula'ons,and all applicable California laws. <br /> Signed Title/Company President/CEO-Technicon Engineering Services, Inc. <br /> Print Na Darren G.Williams Date iy/aoC3 <br /> r DEPARTMENT USE ONLY A <br /> SITE MAP IN UNIT IV FILE-SITE �DDRESS� !l/ 7 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED �� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION 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 <br /> R# <br /> $125x3 3�� /90y. SR# rC/ST/ P91 <br /> Roo / <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 />