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HE E COPY ora (" yL3b31i1t�1N?UdN SAN JOAQUIN COUNTY bIOZ L 4 911GN 2` y VIRONMENTAL HEALTH DEPARTMENT LOP � 600 East Main Street, Stockton, GA 95202-3029 SITE MITIGATION 20 68-3147 Fax:(209) 468-3433 Web:www.swgov.org/eh UNIT IV �. : 9(IFORN 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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental He�SIth I)e rtment. Site Location 10100 W. Linne Road Cross Street South Tracy Boulevard City Tracy Zip'( APN 253-120-41 Property NOV Ameron Owner Address 10100W. Linne Road City Tracy ipm—W Phone 209 836-5050 C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 ConsultanttSub Cntr LTE Environmental Address 6620 NW 38th Terrace City Gainesville, FL Lic 9697 Phone 352 371-1770 Billable Party LTE Environmental Address 6620 NW 38th Terrace City Gainesville, FL Zip 32653 Phone 352 371-1770 GIS Coordinates:X 37.693731 Y -121.428283 324c, h03 —/ 1. 28 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) [$SOIL BORING IDs 61 through B10 ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL ❑PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE 106 SOIL BORING N PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Nr Smme.ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 Ib portland Cement and 6 gallons Water _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5-10 feet bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING CKNo❑Yes:Casing Dia: Casing Depth: Boring Dia:_ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all laws. Signed a Title/Company Geologist Print Name Brian Millman Date DEPARTMENTUSEONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /0/cx> �•�.f NNE dC0 r -(p4m C WORK PLAN DATED A VCrkST ?.4 2,)"1' APPLICATION ACCEPTED BY OiJK"P-1 DATEILSSMD -12.15 AREA /4917 GROUT INSPECTION BY FINAL INSPECTION B ATE 8 DESTRUCTION INSPECTIO BY DATE COMMENTSICONDITIONS: A{� goi� on Gtota.-.Lf , ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Ro# INVOICE REQUEST PR# a o5 $16, 1 13r> O Pt ?5-- weorumic sR# ,>o2V t�p 'JJ�p X16 3508 PR# (2900 C-57IL WC �LWAIVER v� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT U ENCROACHMENTDOC A,4 EHD29-01 01/13/12 WELL PERMITAPP