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to.� o. SAN JOAQUIN COUNTY }:m .o� ENVIRONMENTAL HEALTH DEPARTMENT LOP • 600 East Main Street,Stockton, CA 95202-3029 SITE MITIGATION _ o-� Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.si4ov.org/ehd UNIT IV at-.- �rFo WELL & 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 Health Department. 30350 S. Tracy Boulevard , Site Location Cross Street 14A City Tracy ZJp 95762 APN 235-130-11 ProOv,ng� CEMEX Address Golden Foothill,Ste 200 El Dorado Hills�p 95762 Phone (916)941-2920 C-57 Contractor Fisch Drilling Address 3150 JOHNSON ROAD City HYDESVILLE Lic 683865 Phone (707) 768-9800 ConsultentlSubCntr SOMA Env Eng. Address 6620 Owens Drive, Ste A City Pleasarton LIC PE C042928Phone (925) 734-6400 Billable Party SOMA Env Eng. Address 6620 Owens Drive, Ste A City PleasanLon Zip 94588 Phone (925) 73.1-6400 GIS Coordinates:X 6293331 Y 2071755 CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELt1BOR1NG(CPT,GEOPROSE,HYDROPUNCH,HANO-AUGER.OTHER) EISOILBORING IDs 173-1, CB-2, CS-3, CB-4, C2-5, C9-6, CB-7, CB-8 ❑WELL IDs ❑OTHER IDs TYPE&It OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 14A _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _©SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(le.Air Smme.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Cement ❑OTHER: [D OTHER:DPT (geoprobe)APPROX.BORING DEPTH 15 Feet ❑BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING O No❑Yes:Casing Dia: NA Casing Depth: Boring Dia: COMMENTS: Borings will be abandoned upon soil sampling, no water sampling is anticipated NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) Fr BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I haver this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all appii California Laws. Signed Title/Company Ii�Gs � Print Name �l�l/.� .SE � e- Dale hDEPART ENT USE ON Y SITE MAP IN UNIT IV FI ITE A DRESSv SL/ WORK PLAN DATED �I APPLICATION ACCEP B DATE iEjSUED !Z AREA T GROUT INSPECTION BY FINAL INSPECTION BY DATE 1 /7 ?U Il DESTRUCTION INSPECTION BY DATE COMMENTSICONDIT IONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3S5 5125X l ( ZSR l ZL/7 b�O6 �03 [2 t� 7( L I `� ��— R 00 4 S I PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC