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1 SAN JOAQU[N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION_ 1868 Hazelton Avenue, Stockton, CA 95205-6232 _ UNITV", ��a•.-i ;:.�,P Telephone: (209) 468-3147 Fax: (209)468-3433 Web:www.sigov.org/ehd rf WELL & BORING PERMIT APPLICATION l FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION�Y `T. ��)'� f NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �._, i'T".!.l..y{ �,I IN Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app"mon is mtad In bom iiartc with San Joaquin County D velopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department t'J'l(, I ~ I Site Location 99 st 6th Street Cross Street E Street City/State Tracy,CA Zip 45178 APNGity-3tmet cy p( Property Owner City of Tracy Address 333 Civic Center Plaza City/State Tracy,CA Zip2aV15 Phone(209)831-6400 Technicon Engineering Servi 4539 N.Brawle Ave.#108 Cit /State Fresno,CA L-c 't'Si$ Phone (559)276-9311 C-57 Contractor ��ress Y Y _ _ onsultant/Sub Cntr Address City/State 1,r - _— Phone Billable Party Technicon Engineering Address 4539 N.Brawley Ave.#108 City/State Fresno.CA Z o *s.'IZ Phone(559)276-9311 IS Coordinates:X N/A Y N/A 1 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs — ❑WELL IDs I ❑OTHER IDs i TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE ' "EL WELL CASING DIA: I _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE A +* FL ❑PVC ❑ OTHER I _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREae [I AUGERS ❑HOSE El PIPE I _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MA)GW s -4 IS 30 FT) _❑INJECTION fl e.AirSgarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH %FFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Apth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS CM k"L'j- KMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MF_Yt+��.w,:,K ;., .-AT APPLY) _j_#OF WELL(S)TO BE DESTROYED ®OVER-BORE DLtMr LACHES TO DEPTH OF 26.5 FT WELL IDs: MW-1 MW-2 and MW-3 ❑PRESSURE GRCA FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FIS FT BELOW SURFACE TREMIE TYPE TO BE USED:EI AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAA-1>3 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR T� mss APPOINTMENTS I I hereby certify that I have prepared this application and that the work will be done in accordance w M Sm Jam: aunty Ordinances,Rules and Regulations,and all applicable California laws. Signed Title/Company President/CEO Tecft- ineering Services, Inc- Print Na Darren G.Williams Dasa .; o?OCg r. DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSLA D �'_ %�AREA GROUT INSPECTION BY L FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE _ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ! SERVICE RO# INVOICE REQUE ST PR# �O $125x 973 /�Ofi � SR# R 5500 PR# (2900 C-57 WC WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 r WELL PERMIT APP i "SCG