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o <br />.' SAN JOAQUIN COUNTY ORIGINAL <br />ENVIRONMENTAL HEALTH DEPARTMENT t,p <br />�' '• RV C <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 SI kTGi <br /><< Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />FpCt i <br />WELL & BORING PERMIT APPLICATION OC I M014 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM EDIATIC VMONMENT LHEALT- <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 />Site Location 21070 Reeve Road Cross Street Bethany City/State Tracy,CA Zip APN 209-300-15,11 <br />Propertp <br />Owner Tracy Dairy Rental Joint Venture Address 4403 Bear Mountain <br />C-57 Contractor Technicon Engineering Address 4539 N. Brawley Ave. #108 <br />Consultant/Sub Cntr John Minney Address 17137 Road 37 <br />Billable Party Lee Smith Attorney Address 7815 N. Palm #200 <br />GIS Coordinates: X 121 29"53" Y 37 46' 17.37' <br />37•7BR r 1rzt. V9g1ff <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />❑ WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />_® MONITORING M HOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) <br />_❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER <br />City/State BakersfieldZip 93313 Phone 661-836-1179 <br />City/State Fresno,CA Lic 767888 Phone 559-276-9311 <br />City/State Madera Lic CE 32537 Phone 559-275-5937 <br />City/State Fresno Zip 93711 Phone 559-447-5700 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 10" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS SCH 40 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED: ❑ Yes ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS Neat Cement <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 25 ❑ BOLTED TRAFFIC BOX OR IN STOVE PIPE <br />CONDUCTOR CASING X 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 />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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable California laws. <br />Signed <br />Print Name Darren G. Williams <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED AP94 <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />u <br />0 <br />Title/Company President/CEO Technicon Engineering Services, Inc. <br />Date 1 C L f; ' -i- <br />DATE <br />FINAL INSPECTION BY <br />DATE <br />/,Q4 <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />I RO # INVOICE <br />PR # <br />2 ?o <br />$ Vex (4�rr <br />SR# <br />g00)�p <br />pQC <br />229 0 r ` 7aXJ J <br />C-57 // WC ✓ WAIVER /t ff- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (i ENCROACHMENT DOC <br />EHD 29-01 5/09/12 WELL PERMIT APP <br />