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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> { SITE MITIGATION <br /> • `• 600 East Main Street, Stockton, CA 95202-3029 V <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wwwsictov.ora/ehd <br /> EC <br /> ��FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUL 2 6 2011 <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 EomVEALTH <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ICES <br /> Ahem Road(Highway 33) Schaefer Road Vernalis 95385 N/A(UPRR ROW) <br /> Site Location Cross Street City Zip APN <br /> Property Union Pacific Railroad 1400 Douglas St.STOP 1690 Omaha,NE 68179-1690 (402)544-8563 D <br /> Owner Address 9 City Zip Phone <br /> C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite ACity Lic <br /> Phone (530 Woodland 906899 661-3600 <br /> ) <br /> Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 Cit, Oakland Lic N/A Phone (510)466-7148 <br /> Billable Party SAIC(see above) Address City Zip Phone <br /> GIS Coordinates:X -121.290991 Y 37.634037 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> IXj NEW WELUlBORING(CPT GEOPROB YDROPUNCH,HAND-AUGER,OTHER) <br /> U SOIL BORING IDs A,C,E,F,G.J,L,M,N,P.Q <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE X PIPE <br /> _tx)SOIL BORING W PUSH POIN (GP/ PT) GROUT SEAL PUMPED:❑Yes LxJ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(.e.Airsoarae Ozones❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet Ings ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑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 APPLY) <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 <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 /> I hereby certify that I fps prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and ppl ble California laws. <br /> Signed Title/Company ¢ y� <br /> Print Name Date lr r <br /> DEPARTMENT USE ONLY p <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED / ' O70 <br /> APPLICATION ACCEPTED BY ( DATE`IrSS ED Z 17 AREA <br /> GROUT INSPECTION BY/ FINAL INSPECTION BY DATEYSIt 7 <br /> DESTRUCTION INSPECTION BY DTE <br /> COMMENTS/CONDITIONS: wpa� f <br /> ACCOUNTING ONLY: AID# AC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ))�� ^� / REQUEST PR# <br /> $122x 1 ZZ LC O� 7 / /-.1 SR#001,7//.2-- <br /> RO <br /> # <br /> l (353sool <br /> PR# <br /> _ (2900;0SOF0,1 !I <br /> C-57 _ WC WAIVER_ _ _ C-57 LETTER OF AU T HORIZATION TO SIG`:PERMIT ENCRO:-CWJENT DCC <br /> EH0 29-01 07/28/10 — 4:i�•_L==R(•A;T.=PR <br />