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�n)AS C (Dpyi <br /> 4D'K• SAN JOAQUIN COUNTY <br /> Op. ... o <br /> 61 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �ISITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> qa Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sitlov.or0leh UNIT IV <br /> `)FOR <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 /> 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 <br /> Joaquin County Der lopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> I I :W i 11P✓SFr 10.0 Z <br /> Site Location 19 r I ISFdiR@ WSN' r dross Street N Center Street City/State Stockton Zip 4)65� APN 139-020-03 <br /> Property W,10/4p yarJ(/NC^-I ;u\ 5(24 j7;C A wrz—or— <br /> Owner AR60' Address P.O.BOX 7257' City/State 'San Ramon Zip • 3• Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State west Sacramento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr JM&AD•BtNT+41WAddress 8; Q0T77r4.AANa Sarva' G City/State UpYtgpny6 Lic Phone 9Z5 17} 3$0) <br /> Billable Party AT<AMTIC R406rE06Address Po Bog 7117 City/State SQA'O'*Wip 92583 Phone L - ,275. 3807 <br /> GIS Coordinates:X 17.4G67y Y -fl.l•.Z••(•Yg8 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 38 FT) <br /> —❑INJECTION(Is NrSparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 1 #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-8 E PRESSURE GROUT TO DEPTH OF 40.5 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 6GAL OF WATER:ONE 94 LB SACKOF PORTLAND GEMENT ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE M PIPE 0 MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <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 /> Regulations,and all applicable California lawn /s.. <br /> Signed 'i ilk Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON DUDA Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /fie f• toop-0 /WG- W ej:J /I SIW_0n0 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J•'�' c7 l9,CtrG o+Z DATEISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 SREREQUEST PR#VICE RO# INVOICE <br /> 3502 $ 130, 1 o SQ��8 Coccwr, l/'ZN-ly SR# 7/083 <br /> 35E:>3 390 (3500) <br /> PR# <br /> 2900) <br /> C-57 y WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT P-� ENCROACHMENT DOC.." <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />