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Pa SAN JOAQUIN COUNTY <br /> • .IN <br /> EM. .JNMENTAL HEALTH DEPARTM fL E C 0 LOP <br /> 1 SI E MITIGATION <br /> • v 600 East Main Street, Stockton, CA 95202-3029 <br /> �4•.-„ , ..;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si4ov.orcdel�d <br /> WELL & BORING PERMIT APPLICATION ''II�IIL 19 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOW <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��1��11�V/�'qqONMENTALHEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is 17rd ;P0p3Ept1A(DE8, <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmen�t'��^�11Y•11 <br /> Site Location 1181 Zuckerman Road Cross Street N/A(McDonald Island) City Tracy Zip 95234 APN 129-080-52 <br /> Property <br /> Owner PG&E-Attn Bob Gray Address 3400 Crow Canyon Road City San Ramon Zip 94583 Phone 925-415-6355 <br /> C-57 Contractor Woodward Drilling Address 550 River Road City Rio Vista Lic 710079 Phone 707-374-4300 <br /> Consultant/Sub Cntr ARCADIS Address 5150 EI Camino Real#D21 City Los Altos Lic N/A Phone 650-469-7229 <br /> Billable Party PG&E Address 3400 Crow Canyon Road City San Ramon Zip 94583 Phone 925-415-6355 <br /> GIS Coordinates:XY_ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ; -NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs MW-01 <br /> ❑OTHER IDs <br /> TYPE Sr#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIE CATIOQNSS <br /> XMONITORING ElHOLLOW STEM DIA.OF BOREHOLE 3.5„ 6❑ U ICT IPLE [IMULTI-LEVELWELL CASING DIA: <br /> —[I EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS h.40 TYPE OF CASING: ❑STEEL XPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6' TREMIE TYPE TO BE USED: ❑AUGERS XHOSE ❑PIPE ` <br /> ❑SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes)(No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 17 feet XBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS:Direct push installation of pre-packed well <br /> CONDUCTOR CASINGXNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <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 1 <br /> GROUT SPECIFICATIONS ❑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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules a� <br /> lt <br /> Regulations,apd all a cab a California laws. /I <br /> Signed Jr��i.t�- Title/Company 1(()/rt„e, t iti"la.1e«��r�,r7Y«cC��S <br /> Print Name All r a�✓L eoS+1"Z Date 1311 '� <br /> DEPARTMENT USE ONLY Z9(,o *4 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATEDmED <br /> APPLICATION ACCEPTED BY DATE AREA D6 <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 <br /> REQUEST I PR# <br /> ZQo I $ 122 x I /�G'•/ SR# <br /> 290 3 �6�•� 200 0 16 <br /> C-57 WC V WAIVER C-57 LETTER OF AUT TI TO ENCROACHMENT DOC <br />