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• FILE COPY <br /> ,: •,. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 'P 9a LOP <br /> 1868 HazeRon Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sIqov.orcj/ehd. <br /> / o <br /> WELL & BORING PERMIT APPLICATION <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 tha 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 149S3SmrtF Aipn�ua. Cross Street Lathrop Road City/Slate Mantcca.CA Zlp 95336 APN /98-030-3/ <br /> Property <br /> Owner Union Pacific Railroad Address 1400Douglm Street ST'DFI030 City/State Omaha,NE Zip 68179 Phone 402-544-8826 <br /> C-57 Contractor Cascade Dn7ling Address 3020.0.1e CitylSlale CAr Lie 938110 .Phone 916,638.1169 <br /> Cons.ultant/Sub Cntr CRA Address 5900 Hollis St.Suito A ChylState EmerYv me,CALic 855376 'Phone 510.420,0700 <br /> Billable Party CRA Address 5900 Halts St,Suds A Ctty/State Emervville,CA Zip 94608 Phone 510.420,0700 <br /> GIS Coordinates:X Y ' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING.DIA: <br /> _I-)EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _D SOIL BORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION Its A,sae,oe.Drmat❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: D OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Die:_ <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 /> __L__#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10 1/4 NCHES TO DEPTH OF 28 FT <br /> WELL IDS: MW-3,MW-4,end MW-5 ❑PRESSURE GROAT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [I HOSE El PIPE - ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> S.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 appllcabis California laws. <br /> Signed � � --r� TKIe/Company (�-,er2_ 09 �RO'-"t <br /> Print Name AJ,,,U...-..... Date Q-4/2 /LS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 157-fr i S• 14 rR poarimtllM <br /> WORK PLAN DATED FQRu Aft 7, 7473 <br /> APPLICATION ACCEPTED BY J. Huw'1 DATE UE AREA �G 9 <br /> GROUT INSPECTION BY FINAL INSP TIO DATES 3 C <br /> DESTRUCTION INSPECTION <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID FAC# <br /> PE CODES FEEINFO AMT REMITTED CHECKt RECV'D BY DATE SERVICE PR <br /> R# INVOICE <br /> REQUEST ' P <br /> (32 $125x. 3 375- yly [e 4! au)u7a 2l3-! SR# (4(9 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> 057 � WC WAVER Vf4., C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ri ENCROACHMENT DOC <br /> EHD 29-01 6/09/12 WELL PERM APP <br />