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ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orglehd UNIT IV C1POR 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 10 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. Site Location 26933 Hansen Rd Cross Street W Schulte Rd City/State Tracy/CA Zip 95377 APN 20911006 Property Musco Family Olive 17950 Via Nicolo Trac /CA 95377 209-229-7055 Owner Address City/Stale Y Zip Phone _ C-57 Contractor V & W Drilling Address 3806 Duck Creek Drive City/State Stockton/CALic 720904 Phone 209-469-7700 Consultant/Sub Cntr 'l'cnaphase Engineering Address 1404 Franklin St., Ste. 600 City/Slate Oakland/CALic 960398 Phone 510-326-1473 Billable Party Musco Family Olive Address 17950 Via Nicolo City/State Tracy/CA Zip 95377 Phone 209-229-7055 GIS Coordinates: X 6266637.181 ft Y 2082078.256 ft (State Plane Coordinate System, NAD83) CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs © WELL IDs MW isg PZ -i PZ -9 ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 ❑ MONITORING W HOLLOW STEM DIA. OF BOREHOLE 10 -inch [:]MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vaporl Water ❑ HAMMER/DRIVEN CASING THICKNESS SCII. 80 TYPE OF CASING: ❑ STEEL M PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 145 feet TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE Q PIPE _❑ SOIL BORING ❑ PUSH POINT GP/ CPT ) GROUT SEAL PUMPED: [2Yes❑ No MAXIMUM FRIEZE FAL DEP/�IT S 30 FT) �[ _ &M'e t 10.35 _❑ INJECTION 11 e Air Soaroe Ozone/ ❑ HAND AUGER GROUT SPECIFICATIONS eft f n Nt.G�.V U( ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 180 feet ❑ BOLTED TRAFFIC BOX OR EI STOVE PIPE CONDUCTOR CASING ® No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: 3 00) 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 rO 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, a d -all app/ le Califo a law /.�•-----` - ytii — Signed Title/Company Principal Geologist & Vice President / Terrapha�� NT �C�VFrI Print Name Andrew Romolo Date 10/14/2014 00 2026, a DEPARTMENT�� USE ONLY SAIV JO SITE ADDRESS (� ( ,c W r �T t N FNi55AQl ' SITE MAP IN UNIT IV FILE - O WORK PLAN DATED /Vjy APPLICATION ACCEPTED BY —�ALNP'!6 xw DATE IS A /VT GROUT INSPECTION BY FINAL INSPECTION BY DATE �G-1 —Av� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE 2 d% $�� 3 3 iSQ lv 2r� SR# 0 7oall 3 00) ��(PS1J (p9 0) C-57_� WC t-' WAIVER & � C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCS_ EHD 29-01-5109/12 WELL PERMIT APP