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10 SAN JOAQUIN COUNTY <br />op... <br />cZ ENVIRONMENTAL HEALTH DEPARTMENT <br />. - 600 East Main Street, Stockton, CA 95202-3029 <br />�4t FaR�';P Telephone: (209) 468-3454 Fax: (209) 4683433 Web: www.sigoY.orolehd <br />LOP <br />SITE MITIGATION <br />UNIT IV <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 />Appficalion 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 <br />Joaquin County Development Tille, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />SilLocation 75 E. Alpine Avenue Cross street <br />Property <br />N. EI Dorado Street <br />Owner Wendy M Berndt Trust Adder PO Box 1810 <br />cS7Contractor Woodward Drilling Co Adds 550 River Road <br />ConsultantfSub Cntr Cardno ERI <br />Billable Patty Cardno ERI <br />GIS Coordinates: X Y <br />SOIL BORING <br />WELL IDs AE <br />OTHERIDS <br />city Stockton Zip 95204 APN 115-140-07 <br />City Aptos Zip 95001 Phone <br />City Rio Vista Uc 710079 Phone 707-374-4300 <br />Address 601 N. McDowell Boulevard City Petaluma LiC Phone 707-766-2000 <br />Address 601 N. McDowell Boulevard City Petaluma Zip_.94954 Phone 707-766-2000 <br />GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER) <br />TYPE & # OF WELLIBORING <br />INSTALLATION TYPE <br />_❑ MONITORING <br />[X HOLLOW STEM <br />5J® EXTRACTION: Valved Water <br />❑ HAMMER/DRIVEN <br />_O SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />_O SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />_5_® INJECTION 4e le Somas. Oiarrel <br />❑ HAND AUGER <br />_O OTHER <br />❑ OTHER <br />DIA OF BOREHOLE 8 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 -Inch <br />CASING THICKNESS Schedule 40 TYPE OF CASING: [ STEEL IN PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 36 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 09 PIPE <br />GROUT SEAL PUMPED: ® Yes ❑ No (pMA�X(.I.MU^�Mt FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS I Vy',�T T C WI FA %�_— <br />APPROX. BORING DEPTH 40 15 BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING I2f No ❑ Yes: Casing Dia: Casing Depth: Boring Dia - <br />COMMENTS: AS Wells will be dual�mplefiw (Two 14nch Schell 80 wells In a 8' diameter boring) set at W and 75 feel bgs. Hydrated bentonite between wens. Grout pumped Q rough tamie pipe to 4&. Traffic Box <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />AOFWFU(S)TOBE DESTROYED LOVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that 1 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 <br />Print Name <br />Tiue/Company Y�r-v�+•�+. ` Low d-o0.C61—zo�avA.q cr .0" . <br />n.ro G_ 1".l _ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 'FS GlilN <br />WORK PLAN DATED 'SYS o` "PI -k o(.et.-±- 1 S <br />IL <br />APPLICATION ACCEPTED BY/t�n.�.c.. o+-� DATE ISSUED t L AREA <br />rA <br />GROUT INSPECTION BY t� FINAL INSPECTION BY U_�-L-L:�� DATE A/La/ 1� <br />DESTRUCTION INSPECTION BY DATE / , <br />COMMENTSICONDDTONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />R <br />ROEQUEST PR# # <br />INVOICE <br />;L-Lol <br />31228 10 <br />117.2-0,00 <br />0312. <br />r <br />iI <br />SR# <br />rtab j <br />3 66 r vo <br />Ro� <br />PR # <br />2900 <br />C-57 ✓ INC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 2901 07/28(70 WELLPERMIT APP <br />