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oV[ly...,c SAN JOAQUIN COUNTY z - ENVIRONMENTAL HEALTH DEPARTMENT LOP G0 SITE MITIGATION 600 East Main Street,Stockton, CA 95202-3029 Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orq/ehd UNIT IV 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 NA 95762 235-130-11 Site Location Cross Street City Tracy Zip APN Property 5180 Golden Foothill.Ste 200 E1 Dorado Hills Owner CEMEX Address City Zip 95762 Phone (916)941-2920 C-57 Contractor Fisch Drilling Address 3150 JOHNSON ROAD City HYDESVZLLE Lic 683865 Phone (707) 768-9800 Consultant/SubCntr SOMA Env Eng. Address 6620 Owens Drive, Ste A City Pleasanton LICPE C042928Phone (925) 734-6400 Billable Party SOMA Env Eng. Address 6620 Owens Drive, Ste A City Pleasanton Zip 945BB Phone (925) 734-6400 GIS Coordinates:X 6293331 Y 2071755 CONSTRUCTION WORK TO BE PERFORMED: x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) 0 SOIL BORING IDs CB-1, CB-2, CB-3, CB-4, CB-5, CB-6, CB-7, CB-8 ❑WELL IDs ❑OTHERIDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL O PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _©SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ne.AlrSnaMe Drone)❑HAND AUGER GROUT SPECIFICATIONS Cement _❑OTHER: M OTHER:DPT (geoprobe)APPROX BORING DEPTH 15 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: NA Casing Depth: Baring 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) n 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 TO Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pared this application and that the work will be dono in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applt California Laws. n Signed Title/Company Print Name �ANo1/��14 —T Dale nh//L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FI ITE A DRESS 3-12 Z> Z- WORK PLAN DATED APPLICATION ACCEP40 BY DATE ISSUED. /24 !Z AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 210 I DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE /� REQUEST PR# 3 S6 S 125 x ( ( Z� f 2,L/-7 41ezzs So3 12 t( 7/ � I Y /2- Rao 4 S PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC