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F�CEIVS& IINAL <br /> "' `L <br /> q+"n.. SAN .1COUNTY 1 GOAQUIN <br /> �II(JI <br /> ENVIRONMENTAL HEALTH DEPARTMENT N 13 2014 LOP <br /> SITE MITIGATION <br /> I!' 1868 Hazelton Avenue, Stockton, CA 952 NMENT ITH UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: S <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 /> SiteLocation30350 S. Tracy Blvd Cross Street NA City/State Tracy Zip 95377 APN 235-130-11 <br /> Property CEMEX 5180 Golden Foothill, Ste 200 E1 Dorado Hills 95762 <br /> Owner Address City/State Zip Phone (916)941 2920 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez LiC 485165 Phone (925)313-5800 <br /> Consultant/SubCntr SORA Env. Ena_q. Address 6620 Owens Dr., Ste A City/State Pleasanton Lic PE C42928 Phone (925)734-6400 <br /> Billable Party SOMA Environmental EnggMdreSS 6620 Owens Dr., Ste A City/StatePleasantonZip 94588 Phone (925)734-6400 <br /> GIS Coordinates X 6293197 Y 2071815 <br /> 37,&PO-7 —1 zJ. g2LR 5 <br /> CONSTRUCTION WORK TO BE PERFORMED: Not Applicable <br /> ❑NEW WELLIBORING(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(.e.Art Soawe.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. Bonng 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 /> 1 #OF WELL(S)TO BE DESTROYED ©OVER-BORE DIAMETER OF 4 INCHES TO DEPTH OF 140 FT <br /> WELL IDs: MW-4 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland &* entonite ❑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 certity that 1 ha repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all appl ble alNornia laws. <br /> Signed Title/Company President <br /> Print Name Map Qur Date s112-0�V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS JQ Ss-c) 8 C u <br /> WORK PLAN DATED Iv K Pj0to vt) <br /> APPLICATION ACCEPTED BY „i o cGt�'t DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY 0111E <br /> DESTRUCTION INSPECTION BY DATE /777 <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 /> UZ s125. / r3�145 e ,t _i3 iy� SRX <br /> Sc 3� RO# <br /> - - - - - (3500) — - <br /> PR# <br /> 2900 <br /> C-57 k' WC A" WAIVER ti rZ- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ _ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />