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oa`L!-1. SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a'Lr� SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ' Telephone: (209)468-3454 Fax:(209) 468-3433 Web:vrww.s' ay.or /ehd <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 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 /> 833 East 8th Street S.Sacramento Street CityStockton Zip 95206 APN 177-02-23 <br /> Site Location_ _Cross Street <br /> Property 95747 916-789-5184 <br /> Owner Union Pacific Railroad Address 9451 Atkinson Street City.. Roseville Zip Phone <br /> C-57 Contractor _Penecore Address 1238 Alice St.Suite A City Woodland Lic_906899_Phone 530-661-3600 <br /> Consultant/Sub Cntr_ARCADIS-US _ Address 1410 Rocky Ridge Dr. City Roseville Lic Phone 916-786-0320 <br /> Billable Party Address ._....m,,-_.._. __ <br /> City Zip Phone <br /> GIS Coordinates.X Y <br /> O-NEW WELUON IN?ARK T7t RF R ED <br /> ©©NEW Vi(ELUBORING(CPT GE©PROBE yr}Rf1Pl INCH HANn-Ail(FR (1THFR1 <br /> ` .,.. <br /> ESOIL BORING IDs C--i--to C-6a.�GR 58 C Ea,,C 15a to k 18$�L�-2ba,,,,t�l _q to D- a .Q.-2a B 4aJbtc D 23a to Q-259_D-31 a/bl <br /> WELL IDs c GP-5a GP-7a GP-16a and D-11 a_32 Borings total <br /> ❑OTHER IDs <br /> TYPE R#OF WELUBORING INSTALLATION TYPE C^ucTal ir.Ti IN SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _2 In__ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS ___TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> �1Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ly�l SOIL BORING aX PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —,❑INJECTION tie Alr Snara-.Ozon ❑HAND AUGER GROUT SPECIFICATIONS <br /> '_❑OTHER: CIOTHER; APPROX.BORING DEPTH_10 Fee{ ❑BOLTED TRAFFIC BOX OR E3 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION 111O 1:3K TO 5E PERFORMED. D TR TION METHOD tCHFC}$aL�THAT APPLY <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF_INCHESTO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH o FT BELOW SURrACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:E]AUGERS ❑HOSE ❑PIPE [3 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h velprepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio s,and all a Ii able California Laws. <br /> Signed ! Title/Company t't� <br /> f�,y_e c'1 �j c,r,>'*t<Sf l,�{Z.C`�x'�'S <br /> Print Name cv t tI)C r1ii°1 Date—LI-—Z-t t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> DATE ISSUED AREA <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE_ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RI# INVOICE <br /> rFtAMT REMITTED CHECK# RECV'D BY DATE REQUEST PR <br /> SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />