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"out 0 • <br /> SAN JOAQU►N COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �• P 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Lop <br /> /F•••µN Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www,slgov ora/Ph UNIT Iv <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT <br /> Application is hereby made to San Joaquin County fora EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joaquin CountyDevelopment permit to construct and/or install the work described. This application is made in compliance with San <br /> 4 W Aldrich <br /> Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 174 W A)drich <br /> Property Cross Street Shields <br /> Owner Shea Mountain House LLC City/State Mountain— a 95304 '24Z-o9d f S <br /> C-57 Contractory&W Drillin Address 2630 Shea Center Drive � APN 299.6g}.gq r� <br /> City/State Livermore, <br /> p Address 3806 Duck Creek Drive � 94551 <br /> Consultant/Sub Cntr ENGEO Ci /State Stockton,C Phone 925925-24 <br /> �� Address 580 N Wilma City/state—�£§c 720904 <br /> Billable Party Shea Mountain House LL Phone 209209-4677— <br /> address same as above City/State Ripon,CA Lic <br /> GIS Coordinates:X 37.764129 City/State Phone 925-52� 5 <br /> —�Y-121.549511 ZIp�Phone— <br /> CONSTRUCTION WO �r1 <br /> K TO BE PERFORM D: <br /> ❑NEW <br /> ❑l SOIL BORR ING NG(CPIDsT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL B <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WEI UBORING INSTALL—ON�E CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM <br /> _❑EXTRACTION:Vapor/water DIA.OF BOREHOLE_ 11 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑HAMMER/DRIVEN CASING THICKNESS <br /> ._O SOIL VAPOR PROBE ❑MUD ROTARY ��TYPE OF CASING: �STEEL ❑PVC ❑ OTHER <br /> _�SOIL BORING DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS <br /> 11❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) HOSE ❑PIPE <br /> _11 INJECTION aeAIrS Oz")0 HAND AUGER <br /> _❑OTHER: GROUT SPECIFICATIONS <br /> ❑OTHER:-_APPROX BORING DEPTH <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: CasingDepth:P _ Bonng Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> L_#OF WELL(S)To BE DESTROYED DESTRUCTION MET HOD: CHECKALL THATgppL <br /> WELL IDs: N/A ®OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF ^50 <br /> GROUT SPECIFICATIONS neat cement El PRESSURE PRESSURE GROUT TO DEPTH OF <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE ®PIPE ElEXPLOSIVES FROM FT BELOW SURFACE <br /> TO FT BELOW SURFACE <br /> COMMENTS native op upper 5 feet ❑MUSHROOM CAP AT L?3 FT) <br /> SFT BELOW SURFACE <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 /> Regulation applica le California laws. <br /> Signed Title/Company ENGEO <br /> Print Name )enniferBotelho <br /> Date 04/11/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNT N FILE-SITE ADDRESS l 721 A) �r Ebr(1 F/ P�rF ✓4/uurY77}rnJ /fc.YX,C� <br /> WORK PLAN DATED / <br /> GROUT <br /> �INSPECTION PBTYED SY .1_�1..r6.Cuw� DATE IS A 1690 <br /> FINAL INSPECTION BY DATE .f `'l� <br /> DESTRUCTION INSPECTION BY DATE- <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ;^110 REQUEST I PR# <br /> o $125x ( — <br /> wt R# <br /> ?V <br /> / <br /> 2403 3�5 Ro# <br /> asoo <br /> PR# <br /> (2900) <br /> C-57 L,-- WC _WAIVER "JJ = C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERM <br />