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e .. .- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ` <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> !P Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.siaov.ora/ehd <br /> /FNN <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 /> Site Location 7500 West 11th St. Cross Street Chrisman Road City Tracy Zip 05304 APN Pubic Hghway <br /> Property <br /> Owner ^ Address 475 West Blewelt Road City Tracy Zip 95304 Phone (209)836-0005 <br /> C-57 Contractor Gregg Drilling and Tesfin,Ina Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 <br /> ConsultantfSub Cntr Dal WaWn,PhD.PE,GE Address 1120 Hollywood Ave.No.3 City Oakland Lic GE 28602 Phone (510)330.9118 <br /> Billable Party Address 3323 South Koster Road City Tracy <br /> �d�,t +' )0912910 <br /> GIS Coordinates:X seeamdt.d. y s..n.,iaeE. <br /> CONSTRUCTION WORK TO BE PERFORMED: mAY 0 90 2013 <br /> ❑ NEW WELUBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs_ <br /> ❑OTHER IDs a�1p1(I���AL}-}r[1 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 I <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(Le Ar SDerae Ozane)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Die: 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 THATAPPLv <br /> 11—#OF WELL(S)TO BE DESTROYED 7 VER-BORE DIAMETER OF INCHES TO DEPTH OF- FT <br /> WELL IDS:MWFP-2,MWFP-5,MWS,MWS,MW-7,MWS,MW-9.MW.10,MW-11,MW-13 and MW-19 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Typo II PM Ca ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USEDIM AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS wYMbWwer JXYpp wp mSffl.eu9 IMW43.,se 121 .6 -M1 e¢ysee.,SEE ATTACHWNTSFOR LODRTION~,SITE RAN,GIS LOCRTIONS AND WELL OEPrHS. <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have re red this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appli able Califomia L ws. <br /> Signed t Title/Company Geotechnical Engineer,Dietz Engineering and Construction,Inc. <br /> Print Name Dai Wallkins <br /> Date C. 5 0 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 7Sa0 (J.I ITMST T_Plft9 <br /> WORK PLAN DATED / <br /> APPLICATION ACCEPTED BY O IQ DAT AREA 1 <br /> GROUT INSPECTION BY FINAL INSPECTION BY 9 DATE- <br /> DESTRUCTION INSPECTION BY DATE —Z <br /> COMMENTS(CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC S <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Sot <br /> —$125xif 1375 .21492 CwlurE� g-3_r SR# 7/7 <br /> 3963 %Z5 375 RO# <br /> 3500 <br /> PR# <br /> G57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 2ENCROACHMENT DOC <br />