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0"•4"�'(ryL• �QYny�U �(p • SAN .10AQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENTC L Ld N: 600 East Main Street, Stockton, CA 95202-3029 �4�`-^R. :P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd crFO � WELL & BORING PERMIT APPLICATION AUG 09 2011 FOR WELLSNNON- NONNGS USED FOR CONTAMINNT INVESTIGATIONS AND-REFUNDABLE PERMIT EXPIRES 1YEAR FROM DATE SSUEDREMEH�E�MENTAL f{EgL7'}.j /SERVICES 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 Health Department. Site Location -600 N Sequoia Blvd Cross Street Palm Circle City Tracy Zip 95376 APN 23416001 Property Cit of Trac 333 Civic Center Plaza Trac 95376 209 831-6000 Owner y y Address p City Y 1 Zip Phone ( ) C-57 Contractor pLne Cot /l(I>IO Address 1239 /�IiC.B. Sr ,Scarff A City 1'✓0.1(I r�vtd Lic �D��°I�I Phone 530 6�1 —31°I� Consultant/Sub Cntr SAIC Address 1000 Broadway,guile 675 City Oakland Lic N/A Phone (510)466-7148 Billable Party SAIC Address 1000 Broadway,Suite 675 City Oakland Zip 94607 Phone (510)466-7148 GIS Coordinates:X -121.440461 y37.735135 CONSTRUCTION WORK TO BE PERFORMED: [_1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) DID ]SOIL BORING IDs 10 Ixl WELL IDs MW-1,MW-3,MW-4,MW-5, MW-6,MW-7,MW-8, Ml1,MW- 5,MW-16 ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE =O SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) p ❑INJECTION(,a.Alr Soarne.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface N]OTHER:Well Box Replacement _ 0 OTHER: APPROX.BORING DEPTH r BOLTED TRAFFIC BOX OR ❑STOVE PIPE V CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring ola. COMMENTS Well box replacement(10 wells)and surface casing repair(MW-6) NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY( #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: 0 PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE r1 p TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE {,1 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 C Regulations,and all applicable California laws. Signed _� _� _ Title/Company Project Geologist/SAIC t Print Name Sean Gehlke _ _ _ _ Date_�� I( \ DEPARTMENT USE ONLY A/ ?igloo SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATF ISSLIFD _Vl/7 // AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY _ DATE COMMENTS/CONDITIONS: L,CCOUNTING ONLY: AID# FAC# FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVCERO# INVOICE REQUESTPR$ 12s, SR#Ob3Z.�PR# 2900 SDWC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP 6-11-005