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ORIGINAL SAN JOA " UIN COUNTY r. LOP ENVIRONMENTAL HEALTH DEPARTMENT b t W' ►:�• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV 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 to construct and/or install the work described. This application is made in compliance with San Joaquin Countyel Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. n Site Location 7500 West 11th St. Cross Street Chrisman Road City Tracy Zip 95304 APN 25014017 Property jw"L#g AWs9&gvJ1T5 Owner. O W— r ,1f,arii�ZKe Y Address 475 West Blewett Road City Tracy Zip 95304 Phone (209)83fi 0005 C-57 Contractor Gregg Drilling and Testing,Inc Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 ConsultantJSub Cn�"tr Dsl Wa-fkiFs PHD;PE,-GE Address 1120 Hollywood Ave,No.3 City OaklandLic GE-28602 i (.510)33rr9110 - Billable Party('E pl"°°^gaM Copons6ud on.Inc. .Address 3323 South Koster Road City Tracy"'r"� 7ap 830 • P 0 '"^""� ' 12091632-2970 FFGIS Coordinates:X seo..Ixu4hea:' Y s•a°"°�°° CONSTRUCTION WORK TO BE PERFORMED: l I v [] NEW WELUBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs _ +�iT4l ElWELL IDs t:yJi36ry - ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXT{RACTIOW Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ri.e.AirSoaMe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No[]Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY _CL_#OF WELL(S)TO BE DESTROYED LLJOVER-BORE DIAMETER OF r..— INCHES TO DEPTH OF—.nwroa FT WELL IDS:MWFP-1,MWFP.3,MWFP4,MW-14,MW-15 and MW-15 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Type II Portland Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED � AUGERS ❑ HOSE ❑PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Wells to be aver ddged wlth en B in,dia auger,except MW-14 where a 121n.auger will be used..6EE ATTACHMENTS FOR LOCATION MAP,SITE PLAN,GIS LOCATIONS ANO WELL DEPTHS. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I havp prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all ap cable Califor ' Laws. Signed Title/Company Geotechnical Engineer,Dietz Engineering and Construction,Inc. Print Name Dai Watkin Date O D 3 t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS W'"Ir 6 WORKPLAN DATED NnuC/rf C_,,LG Lott IPU APPLICATION ACCEPTED BY J. DATE IS& _AEA GROUT INSPECTION BY FINAL INSPECTION BY TE r DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 305-C)l $125 x 750 SR# 7 7 4 3J b 3�5 375 q `Z, RO# 3500) PR# 2900) C-57 WC V=WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC