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FILE COPY SAN JOAQUIN COUNTY EWIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION •' `• (� ct`1��AQ�^ X68 Hazelton Avenue, Stockton, CA 95205-6232 iFOiRt��Q �f3iF�(`Y�/�C7/7ev(209) 468-3147 Fax:(209) 468-3433 Web:WVVW.sigov.org/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. /29-3/d_/z Site Location 1181 Zuckerman Road Cross Street n/a McDonald Island City/State Tracy,CA Zip 95204p APN 42490.5 - Propert Owner !G&E-Atln:Bob Gray Address 3400 Crow Canyon Road City/State San Ramon,CA Zip 94583 Phone 925-415-6355 C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista,CA Lic 7100$9 Phone 707-374-4300 Consultant/Sub Cntr ARCADIS U.S.Inc. Address 140 2nd Street,Suite 200 City/State Petaluma,CA Lic n/a Phone 650-469-7229 Billable Party PG&E Address 3400 Crow Canyon Road City/State San Ramon,CA Zip 94583 Phone 925-415-6355 GIS Coordinates:X 6279124.178 Y 2184122.050(NAD 83/ft) CONSTRUCTION WORK TO BE PERFORMED: N NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑■ WELL IDs MW-02,MW-03,MW-04 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 0 MONITORING E HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2• TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0-4.5 TREMIE TYPE TO BE USED: N AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae,ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 16'below ground surface E BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING o No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,add all applicabllifornia laws. Signed _� Title/Company Staff Geologist/ARCADIS U.S.,Inc. Print Na -mory e Ja y PeterDate April 18,2013 DEPARTMENTUSE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1181 2c4fa2094N -bRtUf r T2114y WORK PLAN DATED O/3 APPLICATION ACCEPTED BY .I, yy 4'Cuwc DATE IS 14ftEA lG�t GROUT INSPECTION BY FINAL INSPECTION BY J' BATE i3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE U REQUEST PR# 90I/ $125 x 3 V C�ouu,7E�� 1'1�`! 3 SR# (e707-1 RO# 3500 PR# (2900 C-57 WC ✓ WAIVER IJ Or C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r/ ENCROACHMENT DOC XAV EHD 29-01 5/09/12 WELL PERMIT APP