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NOW", ORIGINAL <br /> 0PQ�ttnf'�' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1$68 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> Telephone: (209)468-3454 Fax:(209)468-3433 Web:WWW:si.aoy.orq/ehd UNIT IV <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 15 East GrantLine Cross Street Holly.Drive City Tracy Ca Zip APN 214-35-004 <br /> Property Ka oor Enter rises IncOwner p Address 461 S Milpitas Boulevard N 1 City Milpitas Zip 95035-5485 Phone (408)933-4422 <br /> C57 Contractor Woodward Drilling Address r550 River Road/P O BOX 336 City Rio Vista CA 94571 Lic 710079 Phone (707)374-4300 <br /> Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave City Modesto Lic Phone (209)579-2221 <br /> Billable Party Address City Zip Phone <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&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF 90REHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION J:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I e.Air Sp2rge Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> -_-.,❑OTHER: ❑OTHER. APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTr)R CASINf;ff4 Nn n Yo.-,r.ASinn nia' Casing Depth Boring Dia' <br /> COMMENTS' _ _ - <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROAgJW ER4LTS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATA L ) <br /> _8_#OF WELL(S)TO BE DESTROYED N OVER-BORE DIAMETER OF 8 412 LACHES TO DEPTH of T""°-0 FT <br /> WELL IDs:fiWI,MW2.fAVI3.MW4,fAW5,NIWB.rAW7,fAWS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS neat cement grout slurry mbc ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE FmI PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS_Whrk to he performed in acnnrdanra to the work to an PRproveri an 01 Anr1.3 with mndifir^tinnc('attanhnd) <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 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 /> Regulatio s,and all app li le California Laws, <br /> Signed Title/Company ''�bod <br /> Print Name L o0cW.4 4-U Date 5 Zai a/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS / 5 (✓r 4 P-#VF1,[ieVE RJ , <br /> WORK PLAN DATED 12' <br /> z� <br /> APPLICATION ACCEPTED BY .L axt4wt DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY 1�SAP,Alt-u`1 DATE�z�b-(3 �^ <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3S02- $125 X l00o 1q4 962- e- rtQ 5-3t-/3 SR# 7 <br /> 3503 375 v!5 Roo) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_t/16L <br />