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r <br /> oPput" c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ;. ` SITE MITIGATION <br /> '�:�• 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT N <br /> c •-� . :4 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siudv.arpleYld <br /> G1FpA <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 Sart Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Deveent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 560 Tracy Boulevard Cross Street 6th Street City/State Tracy,CA Zip 95376 APN-2315 838-687» <br /> Property <br /> Owner City of Tracy Address 333 Civic Center Plaza City/State Tracy,CA Zip95376 Phone (209)831-6400 <br /> C-57 ContractorTechnicon Engineering ServIMMress • 4539 N.Brawley Ave.#108 City/State Fresno,CA Lic 767888 Phone (559)276-9311 !j <br /> ConsultanVSub Cntr Address City/State Lic Phone <br /> Billable Party Technicon Engineering Address 4539 N. Brawley Ave.#108 City/State Fresno,CA Zip 93722 Phone(559)276-9311 <br /> GIS Coordinates:X N/A Y 'NIA <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a_Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING[INo❑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: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> 4 #OF WELLiS)TO DE ROYED �(��/({�y ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 2 6.5 FT <br /> WELL IDs: MWIIrM M and MW-y0 _ ® PRESSURE GROUT TO DEPTH OF 2G,5 FT BELOW SURFACEMW-10 <br /> GROUT SPECIFICATIONS one(1)94Lb Cement/6,5 galilon water _ ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑ HOSE ®PIPE ®MUSHROOM CAP AT(?3 FT) 1 ft FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed Title/Company President/CEO-Technicon Engineering Services, Inc. <br /> Print Na Darren G.Williams <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE DDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BDATE ISSUED �.�/ AREA <br /> GROUT INSPECTION BY FINAL INSPECPObt EIY DATE <br /> DESTRUCTION INSPECTION BY O <br /> DATE <br /> COMMENTS/CONDITIONS: ti/ r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> L/ REOUEST PR# <br /> OCR $125 x Z:�;00. .� `� SR# <br /> 9:503 .37.5 G 3 y7� ��/ 3500-JZd <br /> PR# <br /> 2900 <br /> C-57 WC _WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5!09112 WELL PERMIT APP <br />