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oP4utNc SAN JOAQUIN COUNTY IP ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION l 600 East Main Street, Stockton, CA 95202-3029 UNIT IV \�•_- �/ Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.si_ ov.orglehd i d:: 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 Tltle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 3035D S. Tracy Boulevard NA 95762 235-130-11 Site Location Cross Street City Tracy Zip APN Property CEM=X 5180 Golden Foothill,Ste 200 E1 Dorado Hills 95762 (916)941-2920 Owner Address City Zip Phone C-57 Contractor Fisch Drilling Address 3150 JOHNSON ROAD City HYD£SVILLE Lic 663865 Phone (707) 768-9800 ConsuitandSub Cntr SOMA Env Eng- Address 6620 Owens Drive, Ste A City Pleasanton Lic PE C0429281"hone (925) 734-6400 Billable Party SOMA Env Eng. Address 6620 Owens Drive, Ste A City Pleasanton Zip 94588 Phone_(925) 734-6400 GIS Coordinates:X 6293331 Y 2071755 CONSTRUCTION WORK TO BE PERFORMED: I]NEW WELUBORING(CPT•GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) EI SOIL BORING IDs DP-1, DP-2, DP-3, DP-4,-DP--5,-DP-6, DP-7 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HDLLOW STEM DIA-OF BOREHOLE 2-3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA _❑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 _O SOIL BORING S ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(,e•Air sr>nraa.Qzo e)❑HAND AUGER GROUT SPECIFICATIONS Cement _❑OTHER: D OTHER:DPT (geoprobe)APPROX-BORING DEPTH 25 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dis' NA 0esing Depth: Boring Die: COMMENTS: Borings will be abandoned upon Boil 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 WELLS)TO BE DESTRDYED El OVER-BORE DIAMETER OF INCHES TO DEPTH DF WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?-3 F7)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I hav�'Prepared this application and that the work wit(be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all apLaws. Signed �- Title/Company PC 111 aQ d l Print Name Date — _ r DEPARTMENT USE ON Y SITE MAP IN UNIT IV FILE/SIT ADDRESS �O�JU WORK PLAN DATED APPLICATION ACCEPTED BY DATE SS D AREATI GROUT INSPECTION BY FINAL INSPECTION BY DATE L �� DESTRUCTION INSPECTION BY _ �f DATE COMMENTS/CONDITIONS: bo/� sLtc` "/ 1')l ACCOUNTING ONLY: AID# FRC# PE CODES I FEE INFO AMT REMITTED CHECK;1 RECV'D BY DATE SERVICE RO# INVOICE _ REQUEST PR# 3 S_fl5 s ,25 x /3-/12-- SR# 0041/67 �1�3 7�- > 7�: 3500 PR# f / _ 2900 /v C-57 WC WAIVER C57 LEITER OF AUTHORIZATION TO SIGN PERMIT —ENCROACHMENT DOC