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oAg t • o SAN JOAQUIN COUNTY <br /> LOP <br /> D <br /> ENVIRONMENTAL HEALTH DEPARTMENT w .:. •{ SITE MITIGATION <br /> !� 600 East Main Street, Stockton, CA 95202-3029 I V <br /> . :. :• Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.siciov.oralehd E D <br /> cfk2i <br /> WELL & BORING PERMIT APPLICATION JUL 2 6 2011 <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 comV1F a LICES <br /> HEALTI-. <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �� <br /> Site Location Ahem Road(Highway 33) Cross Street Schaefer Road City Vernalis Zip 95385 APN N/A(UPRR ROW)A <br /> Property Union Pacific Railroad Address 1400 Douglas St.STOP 1690 City Omaha,NE Zip 68179-1690 Phone (402)544-8563 D <br /> Owner <br /> C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite A City Woodland Lic 906899 Phone (530)661-3600 <br /> Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City 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 /> CONST LICION WORK TO BEPERFORMED: <br /> (,NEW WELL/BORING(CPT OEOPROB YDROPUNCH,HAND-AUGER,OTHER) <br /> IJ SOIL BORING IDs A.C,E,F,G.J,L,M,N,P,Q <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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 /> j _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE X PIPE <br /> _IxI SOIL BORING 2rl PUSH POIN (GP/ PT) GROUT SEAL PUMPED:❑Yes Lxl No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION Iie AlrSoarne ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet bgs ❑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 /> #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 /> ij TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> :I 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h e prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatlons,and pp ble Californla laws. <br /> Signed Title/Company ¢ r <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �Q�9^ — r �� a, Y� u <br /> WORK PLAN DATED �<< <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 9 9 <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 /> REQUEST PR# <br /> $122x I ZZ- LG 04 q <br /> ROif <br /> 0) <br /> PR <br /> s 0)o Sb8o�f3 N <br /> i C-57 WC __._:_WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHDAENT DOC__ <br /> EHD 29-01 07/28/10 — WELL FEPMiT-PP <br />