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0 9 RECEIVED <br /> .9I� . SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUN 04 201.9LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232�ENVIRONMENI��i� - T�,t1TION <br /> Telephone:(209)468-3747 Fax:(209)468-3433 Web:wwwsiaovF2&EMFfISEFWt lI� <br /> /FO <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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1447 Mariam Court Cross Street Stonebridge Drive City/State Tracy Zip 95376 APN 250-260-09 <br /> POrty <br /> wnerr Carl Gowan Address 15 West 8th Street City/State Tracy Zip 95376 Phone 209-836-2482 <br /> C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Lic 680227 Phone 800 511-9300 <br /> Consultant/Sub Cntr Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Lic 680227 Phone 800 511-9300 <br /> Billable Party Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Zip 95215 Phone 800 511-9300 <br /> GIS Coordinates:X 37.745998 Y -121.414597 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs B1 through B3 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL O PVC O OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IR PIPE <br /> 3—I$SOIL BORING 16 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes GS No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _❑INJECTION Ii.e.AirSmm.Om ❑HAND AUGER GROUT SPECIFICATIONS Portland Type 1/II Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10 feet bag ❑BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASING[XNo❑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 /> _#OF WELL(S)TO BE DESTROYED ❑OVER-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 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 a I' able Calif nia laves. <br /> 9 P <br /> Signed Title/Company Project Geologist <br /> Print Name Brian Millman Date nit <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS (`&23,&47t <br /> WORK PLAN DATED 1,1 Lt S <br /> APPLICATION ACCEPTED BY Iitl,� ra c- DATE ISSUED r/1-5— 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 SERVICE I RO# INVOICE <br /> REQUEST PR# y <br /> o29oS $130x 3 3 '10 SR# 2-j o$ <br /> R03 3 9 3ao 59, I-vlocl <br /> PR# \y\ <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />