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FILE 10PYWIi' , <br /> ePau n. SAN .JOAQUIN COUNTY <br /> lr. '••p <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siciov.orolehd <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. 20911006 <br /> Site Location <br /> 26933 Hansen Rd Cross Street W Schulte Rd CitylSlate Tracy/CA Zip 95377 APN <br /> Property Musco Famil Olive 17950 Via Nicoto Tracy/CA Zip 95377 phone 209-229-7055_ <br /> Owner y Address Cily/State <br /> C-57 Contractor V&W DrWing Address 3806 Duck Creek Drive City/Stale Stockton/CALie 720904 phone 209-469-7700 <br /> Oaklatd/CALIC 960398 Phone 510-326-1473 <br /> consultant/Sub Cntr'1'crraphase P.ngineedng Address 1904 Frattldin St.,Ste.600 City/State 209-229-7055 <br /> Billable party Musco Family Olive Address <br /> 17950 Via Nicole Oily/State Tracy/CA Zlp 95377 Phone <br /> GIS Coordinates:X 6266637.181 ft y 2082078.256 ft (State Plane Coordinate System,NAD83) <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING(CPT,GEOPROBE,HYOROPUNCH.HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ®WELL to <br /> ❑OTHER to, <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 <br /> I>J MONITORING IW HOLLOW STEM DIA.OF BOREHOLE 110-incl!❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> 3CASIN <br /> _❑EXTRACTION:vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch-80 TYPE feet TREM E TYPE TO BOUS EEL[AUGE O O HOSE }Fj PIPE <br /> _p SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q1Y=_[3 No M_( AXIMUMM FREE FAL I DEPT ��FT) <br /> —0 SOIL BORING , IDr�S <br /> —I]INJECTION(I Air5 O (31 HAND AUGER GROUT SPECIFICATIONS LCAT[A l <br /> _❑OTHER: <br /> [I OTHER: APPROX.BORING DEPTH 180 fee[ ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE <br /> CONDUCTOR CASING®No El Yes:Casing Dia: Casing Depth:__ Boring Dia:_ <br /> COMMENTS: - <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _ LL(S)T09E DESTROYED DOVER-BORE DIAMETERDEP INCHES TO DEPT FT <br /> #OFWE <br /> ❑PRESSURE GROUT TOoDEPOF BEL FT BELOW SURFACE <br /> WELL IDs: ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONSFT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [I HOSE [3 PIPE <br /> ❑MUSHROOM CAP AT(_3 FT) <br /> COMMENTS <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 /> Regulations,a i app le Ca�ii/foJiIa law P PAY NT <br /> / - Tille/Company Principal Geologist&Vice President/Terra h M <br /> Signed _Ty- 10/14/2014 nn�Civil <br /> Print Name <br /> -Andrew Romolo Date <br /> DEPARTMENT D NTT USE ONLYIle SA/V j��yApr''•0,SITE MAP MAP IN UNIT IV FILE-SITE ADDRESS 11 t 1N�LN7Y <br /> WORK PLAN DATED <br /> DATE I A IVT <br /> APPLICATION ACCEPTED BY / 00111 DATE'/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY �y <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 2 6r °�` 3 3 D is a / I o / sR# 0 081 <br /> RO# <br /> ID 0 IKIq PR# <br /> /�f5(PSj 2900 <br /> C-57_ WC WAIVER - 0-57 LETTER OF AUTHORIZATION TOSIGN PERMIT V ENCROACHMENWDOPERM <br /> END 29-01 5109112 <br />